Jackson syndrome neurology. Bulbar alternating syndromes

Alternating syndromes(lat. alternans - alternating; alternating paralysis, cross paralysis) - symptom complexes characterized by a combination of lesions cranial nerves on the side of the lesion with conduction disturbances of movement and sensitivity on the opposite side. Occurs when one half of the brain stem is damaged, spinal cord, as well as with unilateral combined lesion structures of the brain and sensory organs. Various AS can be caused by a violation cerebral circulation, tumor, traumatic brain injury, etc. A gradual increase in symptoms is possible even without impairment of consciousness, with the spread of edema or progression of the process itself.

Bulbar alternating syndromes

Avellis syndrome(palatopharyngeal paralysis) develops when the nuclei of the glossopharyngeal and vagus nerves and the pyramidal tract are damaged. It is characterized on the side of the lesion by paralysis of the soft palate and pharynx, on the opposite side by hemiparesis and hemihypesthesia. (in the diagram - A)
Jackson syndrome(medial medullary syndrome, Dejerine syndrome) occurs when the nucleus is damaged hypoglossal nerve and fibers of the pyramidal tract. It is characterized by a paralytic lesion of half the tongue on the side of the lesion (the tongue “looks” at the lesion) and central hemiplegia or hemiparesis of the limbs on the healthy side. (in the diagram - B)

Babinski-Nageotte syndrome occurs with a combination of damage to the inferior cerebellar peduncle, olivocerebellar tract, sympathetic fibers, pyramidal, spinothalamic tracts and medial lemniscus. Characterized from the site by the development cerebellar disorders, Horner's syndrome, on the opposite side - hemiparesis, loss of sensitivity (In the diagram - A).
Schmidt syndrome characterized by combined lesions motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and pyramidal tract. Manifested from the side of the lesion by paralysis soft palate, throats, vocal cord, half of the tongue, sternocleidomastoid and upper part of the 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, inferior cerebellar peduncle, spinothalamic tract, and sometimes the pyramidal tract. On the side of the lesion, 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; on the opposite side - loss of pain and temperature sensitivity on the torso and limbs. Occurs when the posterior inferior cerebellar artery. Several options are described in the literature.

Pontine alternating syndromes

Raymond-Sestan syndrome noted in cases of damage to the posterior longitudinal beam, middle cerebellar peduncle, medial lemniscus, pyramidal tract. It is characterized by paralysis of gaze towards the lesion, on the opposite side - hemihypesthesia, sometimes hemiparesis. (In the diagram - A)
Millard-Hubler syndrome(medial pontine syndrome) occurs when the nucleus or root is damaged facial nerve and the pyramid path. It manifests itself on the side of the lesion as paralysis of the facial nerve, on the opposite side as hemiparesis. (In 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 lesion and hemiparesis on the opposite side (In the diagram - A).
Foville syndrome(lateral pontine syndrome) is observed with combined damage to the nuclei (roots) of the abducens and facial nerves, the medial lemniscus, and the pyramidal tract. Characterized from the side of the lesion by abducens nerve palsy and gaze paralysis towards the lesion, sometimes by facial nerve paralysis; on the opposite side - hemiparesis and hemihypesthesia (In the diagram - B).

Peduncular alternating syndromes

Benedict's syndrome (upper syndrome red nucleus) occurs when the nuclei are damaged oculomotor nerve, red nucleus, red nucleus-dentate fibers, sometimes medial lemniscus. On the side of the lesion, ptosis, divergent strabismus, and mydriasis occur, on the opposite side - hemiataxia, eyelid tremor, hemiparesis without Babinsky's sign (In the diagram - B).
Foix syndrome occurs when the anterior parts of the red nucleus and fibers of the medial lemniscus are damaged without involving the oculomotor nerve in the process. The syndrome includes choreoathetosis, intention tremor, and hemitype sensitivity disorder on the side opposite to the lesion. (in the diagram - A)

Weber syndrome(ventral mesencephalic syndrome) is observed when the nucleus (root) of the oculomotor nerve and the fibers of the pyramidal tract are damaged. On the affected side, ptosis, mydriasis, and divergent strabismus are noted, on the opposite side - hemiparesis. (In the diagram - B)
Claude syndrome(dorsal mesencephalic syndrome, lower syndrome red nucleus) occurs when the nucleus of the oculomotor nerve, superior cerebellar peduncle, or red nucleus is damaged. It is characterized on the affected side by ptosis, strabismus, mydriasis, and on the opposite side by hemiparesis, hemiataxia or hemiasynergia. (In the diagram - A)

Nothnagel syndrome occurs with combined damage to the nuclei of the oculomotor nerves, the superior cerebellar peduncle, the lateral lemniscus, the red nucleus, and the pyramidal tract. On the side of the lesion, ptosis, divergent strabismus, and mydriasis are noted, on the opposite side - choreoathetoid hyperkinesis, hemiplegia, paralysis of the facial and tongue muscles.

Alternating syndromes associated with damage to several parts of the brain stem.

Glick syndrome caused by damage to the optic, trigeminal, facial, vagus nerves and pyramidal tract. On the affected side - peripheral paralysis (paresis) of the 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 when the nucleus is damaged spinal tract trigeminal nerve at bridge level or medulla oblongata and fibers of the spinothalamic tract. On the affected side there is a disorder of superficial sensitivity on the face of a segmental type, on the opposite side there is a disorder of surface sensitivity on the trunk and limbs.

Extracerebral alternating syndromes.

Alternating syndrome at the level of the spinal cord - Brown-Séquard syndrome- combination clinical symptoms, developing when half the diameter of the spinal cord is affected. On the affected side there are spastic paralysis, conduction disorders of deep (muscular-articular sense, vibration sensitivity, sense of pressure, weight, kinesthesia) and complex (two-dimensional-spatial, 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 top level These disorders are determined several segments below the level of the spinal cord lesion.
When lesions occur at the level of the cervical or lumbar enlargements of the spinal cord, peripheral paresis or paralysis of the muscles innervated by the affected anterior horns of the spinal cord develops (peripheral motor neuron damage).
Brown-Séquard syndrome occurs with syringomyelia, spinal cord tumor, hematomyelia, ischemic disorders of the spinal circulation, injury, spinal cord contusion, epidural hematoma, epiduritis, multiple sclerosis and etc.
True half-spinal cord lesions are 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 options localization plays a role pathological process in the spinal cord (intra- or extramedullary), its nature and characteristics of its course, different sensitivity of the afferent and efferent conductors of the spinal cord to compression and hypoxia, individual characteristics vascularization of the spinal cord, etc.
The syndrome has topical and diagnostic significance. The localization of the lesion in the spinal cord is determined by the level of impairment of surface sensitivity.

Asphymohemiplegic syndrome(brachiocephalic syndrome truncus arteriosus) 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 cortex big brain. On the affected side there is a spasm of the facial muscles, on the opposite side there is central hemiplegia or hemiparesis. There is no pulsation of the common carotid artery on the affected side.

Vertigohemiplegic syndrome caused by unilateral lesion vestibular apparatus and motor zone of the cerebral cortex due to circulatory disorders in the subclavian and carotid arteries with impaired circulation in the labyrinthine (vertebrobasilar basin) and middle cerebral arteries. On the affected side - noise in the ear, horizontal nystagmus in the same direction; on the opposite side - central hemiplegia or hemiparesis.

Optical-hemiplegic syndrome occurs when there is unilateral damage to the retina of the eye, optic nerve, motor zone of the cerebral cortex due to circulatory disorders in the internal carotid artery system (in the basin of the ophthalmic and middle cerebral arteries). On the affected side there is amaurosis, on the opposite side there is central hemiplegia or hemiparesis.

The disease is characterized by damage to the cranial nerves, conduction disorders of motor and sensory functions.

Multiple alternating syndromes are caused by circulatory disorders in the spinal cord, the appearance of tumors localized in the brain stem, especially after traumatic injuries.

Brainstem symptom complexes occur quite often, due to dysfunction of the nuclei or processes of the brain.

The main cause of the syndrome is changes in job functioning cerebral blood flow , in case of tumors, injuries, in people with the disease – diabetes mellitus.

Paralysis or cutting of the limbs develops as a result of the corticospinal tract, and cross-hemianesthesia occurs when the sensory pathways of the lower part of the brain stem are damaged.

Known types of syndromes

In neurology, the following alternating syndromes are distinguished:

bulbar diseases(with damage to the medulla oblongata) - Jackson, Avellis, Schmidt, Walenberg Zakharchenko, Babinsky Nageotte syndrome.
pontine disorders(in case of bridge violation) – Gubler, Fauville, Raymond Sestan, Brissot syndrome.
peduncular syndromes(in the presence of a defect in the cerebral peduncle) - Weber, Claude, Benedict, Nothnagel.

A sure sign of cerebellar damage is characteristic symptoms and approach to treating the disorder.

Causalgia is a symptom characterized by the appearance burning pain at the site of damage peripheral nerves. How ?

Bulbar syndromes

Main bulbar alternating syndromes:

Jackson's disease characterized by damage to the hypoglossal nerve and paralysis of the limbs on the opposite side. The tongue deviates to the side, or its complete atrophy occurs. Sometimes fibrillary twitching is observed during muscle excitability. The person cannot speak clearly, stutters and swallows half of the words. It is almost impossible to understand the patient's speech.
Avellis syndrome affects the glossopharyngeal nerves, causing paralysis of the palate and vocal folds, and swallowing disorder. In such patients, eating is painful, liquid food enters the nasal passage, and solid food enters the intestines with difficulty, and the patient often coughs and chokes when eating.
Schmidt's disease comprises previous symptoms and paresis vocal fold. The person cannot speak and has difficulty eating food.
Wallenberg syndrome Zakharchenko manifested by the appearance of symptoms on the side of the lesion by a lesion vagus nerve, muscle sensitivity disorder throughout the face. In such cases, the patient’s eyes, cheeks, and nose are distorted, while he has difficulty seeing, breathing and hearing. Appearance for a short time distorted beyond recognition.
Babinski Nageotte disease consists of cerebellar signs in the form of lesions of the olivocerebellar tract. The patient does not develop muscles. He can hardly move, his whole body is weakened and exhausted.

Pontine violations

All types of the disease are manifested by paralysis of the facial nerve, distortion of the outer shell of the face.

Pontine alternating syndromes:

Hübler's syndrome- this is a pathological process associated with circulatory disorders in the paramedian arteries, lagophthalmos and severe lacrimation occur.
Foville's disease occurs due to thrombosis of the basilar artery, with cancer metastases and sarcoma. Strabismus occurs and the optic nerve expands. The patient's one eye becomes larger than the other; it may not close at all when blinking or during sleep.
Raymond Sestan's illness manifested by paresis of the area eyeballs, sensory disturbances during movement, hemiparesis on the opposite side. Such people can lie on a doctor's bed in one position for years, without daring to turn half of their body.
Brissot's syndrome distorts the facial muscles on the side of the facial nerve, distortion of the pyramidal tract appears. The cells of the roots or nucleus of the facial nerve are irritated, and reflex spasms appear in the opposite area of the lesion.

Lesions of the cerebral peduncle

Peduncular syndromes:

Weber–Pobler disease develops on the basis of pathological processes in the area of the cerebral peduncles, due to a disorder of ischemic hemorrhage. And also when the legs are compressed by a developing tumor.
Clinical signs of the disease are paralysis of the muscles of the face, tongue and limbs of the central type. Symptoms are caused by a complete or partial cut of the oculomotor nerve. In case of muscle damage, the eyeball deviates towards the temple and “looks” at reverse side paralyzed limbs. If the pathology also affects the optic tract, hemianopsia occurs. The patient develops widened strabismus, he sees poorly and has difficulty distinguishing colors. The pharetic component, clonus of the hands and feet may also develop, and over time, disturbances in the flexion of the wrist protective reflexes will be observed.
Claude syndrome (red core)– captures the fibers of the oculomotor nerve, caused by damage to the branches of the posterior cerebral artery, which supplies lower sections red core. Common cause The onset of the disease is atherosclerosis and syphilitic endarteritis.

General picture of symptoms

There is a set of symptoms characteristic of all types of syndrome:

century;
dysarthria;
swallowing disorder;
partial or complete ophthalmoplegia;
distortion of the eye opening;
complete or partial facial paralysis.

The patient is diagnosed with Benedict and Weber syndromes; the individual form of this type of alternating disease very rarely manifests itself.

Benedict's syndrome

Benedict's syndrome (superior side of the red nucleus) - affects the nuclei of the oculomotor nerve, sometimes the medial lemniscus. Characterized by strabismus, mydriasis, eyelid tremor, hemiparesis.

Possible disturbances of associated eye movements, gaze deviation towards the focus of the disease. Increased general muscle tone, tendon reflexes, and hemorrhage of the posterior cerebral artery in metastatic cancer.

Nothnagel's pathology

Nothnagel's disease (quadrigeminal) - occurs with extensive damage to the midbrain and partial of its base. The main cause is a tumor of the pituitary gland, which, when expanded, compresses the red nuclei and superior cerebellar peduncles.

TO clinical signs ataxia must be included. As the disease progresses, central paresis facial and hypoglossal nerves.

A person speaks poorly, his speech becomes slurred, he has difficulty pronouncing consonants, and he also has difficulty hearing or cannot understand the speech of his interlocutor at all.

There are also eye symptoms, bilateral ophthalmoplegia, medrisis, and ptosis are observed. Visual impairment occurs gradually, first the pupillary reactions change, then gaze paralysis appears (the patient looks up).

Later, internal paralysis of the rectus and superior oblique muscles joins.

Syndromes in diabetic neuropathy

A syndrome develops based on unilateral damage to the brainstem due to traumatic brain injury, peripheral paralysis on the affected side in combination with conduction disorders.

The clinical picture includes isolated or extensive paresis of the abductor angle of the lesion.

The extraocular muscles are innervated and hemiparesis occurs.

Vertigohemiplegic syndrome is a disorder of the vestibular apparatus and motor area of the cerebrum, characterized by loud noise in the ears, horizontal nystagmus to one side, distortion of facial muscles.

There is no pulsation of the carotid artery at the site of the lesion.

The nature of the pathological process can be judged by the dynamics of symptoms; signs of disorders often develop gradually, the boundaries of the lesion correspond to the zone of vascularization.

With hemorrhage in the brainstem, symptoms may increase due to reactive edema and be accompanied by breathing problems, cardiac activity, and vomiting.

IN acute period muscle tone decreases, certain facial features become distorted, speech changes, becomes slurred and absent-minded.

Midbrain syndromes

Symptoms include internal, external and total ophthalmoplegia, the patient's gaze downward, and convergent strabismus. Discordance of eye movements, presence of limb paresis. As well as disturbances in balance, hearing, vision, swallowing and speech functions.

Red core syndrome is manifested by symptoms of damage to the third pair of cranial nerves on the side of the lesion.

Excessive reflex movements are noted during sharp sound stimulation.

Patients may shudder in their sleep for no apparent reason, be afraid of every rustle, moan, throw up their arms and legs, and cannot control facial movements.

Signs of dysfunction of the brain pons:

Vegetative-trophic disorders include:

Syndromes of dysfunction of the medulla oblongata

The clinical picture can be very diverse; in addition to the above syndromes, there is a violation of sensitivity, paralysis of the limbs, failures in coordination of movement, and disorders in the functioning of the cardiovascular system.

Summary

Considering the many varieties of alternating syndromes, the main reason for their successful treatment is timely diagnosis and a professional approach to therapy.

Modern technologies allow high accuracy determine the location of the lesion and promptly prevent its further development.

Alternating syndromes (lat. alterno alternate; synonyms: alternating paralysis, cross paralysis) syndromes that combine damage to the cranial nerves on the side of the lesion with conduction disorders of motor and sensory functions on the opposite side.

Etiology and pathogenesis of alternating syndromes

Alternating syndromes occur with damage to one half of the brain stem, spinal cord (Brown Sequard syndrome), as well as with unilateral combined damage to the structures of the brain and sensory organs. Various alternating syndromes can be caused by circulatory disorders in the spinal cord and brain stem tumor processes with localization in the brain stem, traumatic brain injuries. Brainstem symptom complexes, which occur most frequently, are characterized by damage to one or more cranial nerves on the side of the lesion. peripheral type(due to damage to their nuclei or roots), as well as conduction disorders on the opposite side (hemiparesis, hemiplegia, hemianesthesia, hemiataxia, etc.) due to damage to the fibers of the pyramidal tract, medial lemniscus, cerebellar connections, etc.

There are bulbar, pontine, peduncular and mixed alternating syndromes depending on the location of the lesion (which is important for clarifying the location of the damage).

Clinical picture of alternating syndromes

1. Bulbar alternating syndromes:

Jackson syndrome (medial medullary syndrome, Dejerine syndrome) occurs when the nucleus of the hypoglossal nerve and the fibers of the pyramidal tract are damaged. It is characterized by a paralytic lesion of half the tongue on the side of the lesion (the tongue “looks” at the lesion) and central hemiplegia or hemiparesis of the limbs on the healthy side.

Avellis syndrome (palatopharyngeal paralysis) develops when the nuclei of the glossopharyngeal and vagus nerves and the pyramidal tract are damaged. It is characterized on the side of the lesion by paralysis of the soft palate and pharynx, on the opposite side by hemiparesis and hemihypesthesia.

Schmidt's syndrome is characterized by combined damage to the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and pyramidal tract. It manifests itself on the side of the lesion as paralysis of the soft palate, pharynx, vocal cord, half of the tongue, sternocleidomastoid and upper part of the trapezius muscle, on the opposite side by hemiparesis and hemihypesthesia.

Wallenberg-Zakharchenko syndrome (dorsolateral medullary syndrome) occurs when the motor nuclei of the vagus, trigeminal and glossopharyngeal nerves, sympathetic fibers, inferior cerebellar peduncle, spinothalamic tract, and sometimes the pyramidal tract are damaged. On the side of the lesion, paralysis of the soft palate, pharynx, vocal cord, Horner's syndrome, cerebellar ataxia, nystagmus, loss of pain and temperature sensitivity of half 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.

Babinski Nageotte syndrome occurs with a combination of lesions of the inferior cerebellar peduncle, olivocerebellar tract, sympathetic fibers, pyramidal, spinothalamic tracts and medial lemniscus. It is characterized on the side of the lesion by the development of cerebellar disorders, Horner's syndrome, on the opposite side by hemiparesis, loss of sensitivity.

2. Pontine alternating syndromes:

Millard Gubler syndrome (medial pontine syndrome) occurs when the nucleus or root of the facial nerve and the pyramidal tract are affected. It manifests itself on the side of the lesion as paralysis of the facial nerve, on the opposite side as hemiparesis.

Foville syndrome (lateral pontine syndrome) is observed with combined damage to the nuclei (roots) of the abducens and facial nerves, the medial lemniscus, and the pyramidal tract. Characterized from the side of the lesion by abducens nerve palsy and gaze paralysis towards the lesion, sometimes by facial nerve paralysis; on the opposite side, hemiparesis and hemihypesthesia.

Raymond Sestan syndrome is observed with damage to the posterior longitudinal fasciculus, middle cerebellar peduncle, medial lemniscus, and pyramidal tract. It is characterized by paralysis of gaze towards the lesion, on the opposite side by hemihypesthesia, sometimes hemiparesis.

Brissot 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 lesion and hemiparesis on the opposite side.

3.Peduncular alternating syndromes:

Weber's syndrome (ventral mesencephalic syndrome) is observed when the nucleus (root) of the oculomotor nerve and the fibers of the pyramidal tract are damaged. On the affected side, ptosis, mydriasis, and divergent strabismus are noted, on the opposite side hemiparesis.

Claude's syndrome (dorsal mesencephalic syndrome, inferior red nucleus syndrome) occurs when the nucleus of the oculomotor nerve, superior cerebellar peduncle, or red nucleus is damaged. It is characterized on the affected side by ptosis, strabismus, mydriasis, and on the opposite side by hemiparesis, hemiataxia or hemiasynergia.

Benedict's syndrome (superior red nucleus syndrome) is observed with damage to the nuclei of the oculomotor nerve, red nucleus, red nucleus-dentate fibers, and sometimes the medial lemniscus. On the side of the lesion, ptosis, divergent strabismus, and mydriasis occur; on the opposite side, hemiataxia, eyelid tremor, and hemiparesis (without Babinski’s sign).

Nothnagel syndrome occurs with combined damage to the nuclei of the oculomotor nerves, the superior cerebellar peduncle, the lateral lemniscus, the red nucleus, and the pyramidal tract. On the side of the lesion, ptosis, divergent strabismus, mydriasis are noted, on the opposite side, choreathetoid hyperkinesis, hemiplegia, paralysis of the facial and tongue muscles.

Diagnosis of alternating syndromes

The diagnostic value of alternating syndromes lies in the ability to localize the lesion and determine its boundaries. For example, Jackson syndrome occurs when thrombosis of the anterior spinal artery or its branches, Avellis and Schmidt syndromes develop when blood circulation is impaired in the branches of the artery supplying the medulla oblongata, and Wallenberg Zakharchenko and Babinsky Nageotte syndromes develop in the basin of the inferior posterior cerebellar or vertebral artery. Pontine syndromes of Foville, Brissot, Raymond Sestan occur with damage to the branches of the basilar artery, peduncular syndromes of the deep branches of the posterior cerebral artery, Claude syndrome of the anterior and posterior arterioles of the red nucleus, Benedict syndrome of the interpeduncular or central arteries etc.

A change in symptoms characterizes the cause of the pathological process. Ischemic lesion brain stem, for example, as a result of thrombosis of the vertebral branches, basilar or posterior cerebral artery, leads to the gradual development of alternating syndromes, not even accompanied by loss of consciousness. In this case, the boundaries of the lesion correspond to the zone of impaired blood supply; hemiplegia or hemiparesis is spastic in nature. Hemorrhages in the brain stem can lead to atypical alternating syndromes. This occurs due to the fact that, in addition to the area of the damaged vascular basin, the surrounding brain tissue is also involved in the process due to the development peripheral edema. Acute development lesions in the pontine zone are accompanied by breathing problems, cardiac activity, and vomiting. In the acute period, a decrease is determined muscle tone on the side of hemiplegia.

Alternating syndromes (cross syndromes) are dysfunctions of the cranial nerves on the side of the lesion in combination with central paralysis of the limbs or sensory conduction disorder on the opposite side of the body. Alternating syndromes occur with brain damage (with vascular pathology, tumors, inflammatory processes).

Depending on the location of the lesion, possible the following types alternating syndromes. Paralysis of the oculomotor nerve on the side of the lesion and on the opposite side with damage to the cerebral peduncle (Weber syndrome). Paralysis of the oculomotor nerve on the affected side, and cerebellar symptoms on the opposite side when the base of the cerebral peduncle 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 abducens nerves on the side of the lesion and hemiplegia on the opposite side (Fauville syndrome); both syndromes - with damage to the pons (varoliev). Damage to the glossopharyngeal and vagus nerves, causing paralysis of the soft, vocal cords, disorder, etc. on the affected side and hemiplegia on the opposite side with damage to the lateral 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 syndrome). on the affected side and hemiplegia on the opposite side due to blockage of the internal carotid by an embolus or thrombus (optic-hemiplegic syndrome); absence of pulse on radial and brachial arteries on the left and hemiplegia or hemianesthesia on the right with damage to the arch (aortic-subclavian-carotid Bogolepov syndrome).

Treatment of the underlying disease and symptoms of brain damage: breathing problems, swallowing problems, heart problems. During the recovery period, vitamins and other activating methods are used.

Alternating syndromes (Latin alternare - take turns, alternate) are symptom complexes characterized by dysfunction of the cranial nerves on the side of the lesion and central paralysis or paresis of the limbs or sensory conduction disorders on the opposite side.

Alternating syndromes occur with damage to the brain stem: medulla oblongata (Fig. 1, 1, 2), pons (Fig. 1, 3, 4) or cerebral peduncle (Fig. 1, 5, c), as well as with damage to the cerebral hemispheres brain as a result of circulatory disorders in the carotid artery system. More precisely, the localization of the process in the trunk is determined by the presence of damage to the cranial nerves: paresis or paralysis occurs on the side of the lesion as a result of damage to the nuclei and roots, i.e., of the peripheral type, and is accompanied by muscle atrophy, a degeneration reaction when studying electrical excitability. Hemiplegia or hemiparesis develops due to damage to the corticospinal (pyramidal) tract adjacent to the affected cranial nerves. Hemianesthesia of the limbs opposite to the lesion is a consequence of damage to sensory conductors running through the middle lemniscus and the spinothalamic tract. Hemiplegia or hemiparesis appears on the side opposite the lesion because the pyramidal tract, as well as sensory conductors, intersect 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 pons), c) peduncular (with damage to the cerebral peduncle), d) extracerebral.

Bulbar alternating syndromes. Jackson syndrome is characterized by peripheral hypoglossal palsy on the affected side and hemiplegia or hemiparesis on the opposite side. Occurs due to 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 lesion and hemiplegia on the opposite side. Swallowing disorders (liquid food getting into the nose, choking when eating), dysarthria and dysphonia appear. The syndrome occurs when branches of the artery of the lateral fossa of the medulla oblongata are damaged.

Babinski-Nageotte syndrome comprises cerebellar symptoms in the form of hemiataxia, hemiasynergia, lateropulsion (as a result of damage to the inferior cerebellar peduncle, olivocerebellar fibers), miosis or Horner's syndrome on the side of the lesion and hemiplegia and hemianesthesia on the 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 syndrome; 2 - Zakharchenko-Wallenberg syndrome; 3 - Millar-Gübler syndrome; 4 - Foville syndrome; 5 - Weber syndrome; 6 - Benedict's syndrome.

Schmidt syndrome consists of paralysis of the vocal cords, soft palate, trapezius and thoracocleidomastoid muscles on the affected side (IX, X and XI nerves), as well as hemiparesis of the opposite limbs.

Zakharchenko-Wallenberg syndrome characterized by paralysis of the soft palate and vocal cord (damage to the vagus nerve), anesthesia of the pharynx and larynx, sensitivity disorder on the face (damage to the trigeminal nerve), Horner's syndrome, hemiataxia on the side of the lesion with damage to the cerebellar tract, respiratory distress (with an extensive lesion in the medulla oblongata) in combination with hemiplegia, analgesia and thermaneesthesia on the opposite side. The syndrome occurs due to thrombosis of the posterior inferior cerebellar artery.

Pontine alternating syndromes. Millar-Gübler syndrome consists of peripheral facial palsy on the side of the lesion and spastic hemiplegia on the opposite side. Foville syndrome is expressed by paralysis of the facial and abducens nerves (in combination with gaze paralysis) on the side of the lesion 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 combined movements of the eyeballs on the affected side, ataxia and choreoathetoid movements, hemianesthesia and hemiparesis on the opposite side.

Peduncular alternating syndromes. Weber 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 pathway) on the opposite side. The syndrome develops during processes at the base of the cerebral peduncle. Benedict's syndrome consists of paralysis of the oculomotor nerve on the affected side and choreoathetosis and tremors of the opposite limbs (damage to the red nucleus and dentatorubral tract). The syndrome occurs when the lesion is localized in the medial-dorsal part of the midbrain (the pyramidal tract remains unaffected). Nothnagel syndrome includes a triad of symptoms: cerebellar ataxia, oculomotor nerve palsy, hearing impairment (unilateral or bilateral deafness of central origin). Sometimes hyperkinesis (choreiform or athetoid), paresis or paralysis of the limbs may be observed, central paralysis VII and XII nerves. The syndrome is caused by damage to the tegmentum of the midbrain.

Alternating syndromes characteristic of the intrastem process can also occur with compression brain stem. Thus, Weber syndrome develops not only due to pathological processes (hemorrhage, intrastem tumor) in the midbrain, but also due to compression of the cerebral peduncle. Compression, dislocation syndrome of compression of the cerebral peduncle, occurring in the presence of a tumor temporal lobe or pituitary region, may manifest itself as damage to the oculomotor nerve (mydriasis, ptosis, strabismus, etc.) on the side of compression and hemiplegia on the opposite side.

Sometimes alternating syndromes manifest themselves mainly as a cross-sensitivity disorder (Fig. 2, 1, 2). Thus, with thrombosis of the inferior posterior cerebellar artery and the artery of the lateral fossa, alternating sensory Raymond syndrome can develop, manifested by facial anesthesia (damage to the descending root of the trigeminal nerve and its nucleus) on the side of the lesion and hemianesthesia on the opposite side (damage to the middle lemniscus and spinothalamic tract). 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 area of decussation pyramid paths, with thrombosis of spinobulbar arterioles.

Rice. 2. Scheme of hemianesthesia: 1 - dissociated hemianesthesia with sensitivity disorder on both halves of the face (more on the side of the lesion) with softening in the vascularization zone of the posterior inferior cerebellar artery; 2 - hemianesthesia with a dissociated disorder of pain and temperature sensitivity (of the syringomyelitic type) with a limited focus of softening in the post-occipital region.

Extracerebral alternating syndromes. Optical-hemiplegic syndrome (alternating hemiplegia in combination with impaired function of the optic nerve) occurs when an embolus or thrombus obstructs the intracranial segment of the internal carotid artery, is it characterized by blindness as a result of obstruction of the ophthalmic artery? arising from the internal carotid artery, and hemiplegia or hemiparesis of the limbs opposite to the lesion due to softening medulla in the area of vascularization of the middle cerebral artery. Vertigohemiplegic syndrome due to dyscirculation in the system subclavian artery(N.K. Bogolepov) characterize dizziness and noise in the ear as a result of discirculation in the auditory artery on the side of the lesion, and on the opposite side - hemiparesis or hemiplegia due to circulatory disorders in the branches of the carotid artery. Asphygmohemiplegic syndrome (N.K. Bogolepov) occurs reflexively with pathology of the extracerebral part of the carotid artery (brachiocephalic trunk syndrome). In this case, 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, reduced arterial pressure 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 allows us to determine the localization and border of the lesion, i.e., establish a topical diagnosis. Studying the dynamics of symptoms allows us to determine the nature of the pathological process. Thus, with ischemic softening of the brain stem as a result of thrombosis of the branches vertebral arteries, the main or posterior cerebral artery, alternating syndrome develops gradually, not accompanied by loss of consciousness, and the boundaries of the focus correspond to the zone of impaired vascularization. Hemiplegia or hemiparesis can be spastic. With hemorrhage into the trunk, the alternating syndrome may be atypical, since the boundaries of the lesion do not correspond to the zone of vascularization and increase due to edema and reactive phenomena in the circumference of the hemorrhage. With acutely occurring lesions in the pons, alternating syndrome is usually combined with respiratory distress, vomiting, impaired cardiac activity and vascular tone, hemiplegia - with muscle hypotonia as a result of diaschisis.

Identification of alternating syndromes helps the clinician when conducting differential diagnosis, for which the complex of all symptoms is important. With alternating syndromes caused by lesions great vessels, shown surgery(thrombinthymectomy, vascular plastic surgery, etc.).