Jackson syndrome neurology. Bulbar alternating syndromes

Alternating syndromes(Latin alternans - alternating; alternating paralysis, cross paralysis) - symptom complexes characterized by a combination of lesions cranial nerves on the side of the focus with conduction disturbances of movement and sensitivity on the opposite side. Occurs when one side of the brainstem is damaged spinal cord, as well as with unilateral combined lesion structures of the brain and sense 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 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 is damaged hypoglossal nerve and fibers of the pyramidal tract. 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 from the side of the focus by the development cerebellar disorders, Horner's syndrome, on the opposite side - hemiparesis, loss of sensitivity (In the diagram - A).
Schmidt syndrome characterized by a concomitant lesion motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves, and pyramidal tract. Manifested from the focus of 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, sometimes pyramidal tract. 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; on the opposite side - loss of pain and temperature sensitivity on the trunk and limbs. Occurs when the posterior inferior cerebellar artery. Several options have been described in the literature.

Pontine alternating syndromes

Raymond-Sestan syndrome seen in lesions of the posterior longitudinal beam, middle cerebellar peduncle, medial loop, pyramidal tract. 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 is damaged facial nerve and the pyramidal path. 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 red nucleus) occurs when the nuclei are damaged oculomotor nerve, red nucleus, red-nuclear-dentate fibers, sometimes medial loop. 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 syndrome red nucleus) occurs when the nucleus of the oculomotor nerve, the superior cerebellar peduncle, the red nucleus is 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 seen with nuclear injury spinal tract trigeminal nerve at bridge level 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- combination clinical symptoms, developing with damage to half the diameter of the spinal cord. On the affected side, there are spastic paralysis, conduction disorders of deep (muscle-articular feeling, vibration sensitivity, pressure, weight, kinesthesia) and complex (two-dimensional-spatial, discrimination, 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 of these disorders is determined by several segments below the level of damage to the spinal cord.
With damage at the level of the cervical or lumbar enlargements 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 and 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 options play a role of localization 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 vascularization of the spinal cord, etc.
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 truncus arteriosus) is noted with unilateral irritation of the nucleus of the facial nerve, vasomotor centers of the brain stem, damage to the motor cortex big brain. 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 lesion vestibular apparatus and motor zone of the cerebral cortex due to circulatory disorders in the subclavian and carotid artery 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, the motor zone of the cerebral cortex due to circulatory disorders in the system of the internal carotid artery (in the pool of the ophthalmic and middle cerebral arteries). On the side of the lesion - amaurosis, on the opposite side - 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 system, the appearance of tumors with localization in the brain stem, especially after cranial injuries.

Stem symptom complexes are quite common, due to dysfunction of the nuclei or processes of the brain.

The main cause of the syndrome is changes in the functioning of work cerebral blood flow , in the event of tumors, injuries, in people with the disease - diabetes mellitus.

Paralysis or a cut of the extremities develops as a result of the cortical-spinal path, and cross-hemianesthesia - when the sensitive conducting channels of the lower brain stem are damaged.

Known Types of Syndromes

In neurology, the following alternating syndromes are distinguished:

bulbar diseases(with damage to the medulla oblongata) - the syndrome of Jackson, Avellis, Schmidt, Valenberg Zakharchenko, Babinsky Nageotte.
pontine disturbances(in case of violation of the bridge) - the syndrome of Gubler, Fauville, Raymond Sestan, Brissot.
peduncular syndromes(if there is a defect on the brain stem) - Weber, Claude, Benedict, Notnagel.

A sure sign of damage to the cerebellum - characteristic symptoms and approach to treating the disorder.

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

Bulbar syndromes

The main bulbar alternating syndromes:

Jackson disease characterized by damage to the hypoglossal nerve and paralysis of the limbs on the opposite side. There are deviations of the tongue to the side, or its complete atrophy. Sometimes its fibrillar twitches are observed with muscle excitability. The person cannot speak clearly, stutters and swallows half of the words. It is almost impossible to make out the patient's speech.
Avellis syndrome affects the glosso-pharyngeal nerves, paralysis of the palate and vocal folds, swallowing disorder occurs. In such patients, eating is painful, liquid food enters the nasal passage, and solid food hardly enters the intestines, while the patient often coughs and chokes when eating.
Schmidt's disease comprises previous symptoms and paresis vocal fold. A person cannot talk, hardly eats food.
Wallenberg Syndrome Zakharchenko manifested by the appearance on the side of the focus of symptoms of a lesion vagus nerve, a disorder of the sensitivity of the muscles throughout the face. In such cases, the patient's eyes, cheeks, nose are distorted, while he sees poorly, breathes and hears. Appearance for a short time distorted beyond recognition.
Babinski Nageotte disease consists of cerebellar signs in the form of lesions of the olive-cerebellar pathway. The patient does not develop muscles. He hardly moves, the 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:

Gubler syndrome- this is a pathological process associated with circulatory disorders in the paramedial arteries, lagophthalmos, severe lacrimation occurs.
Fauville disease occurs due to thrombosis of the basilar artery, with metastases of cancer and sarcoma. There is strabismus, the optic nerve expands. In a patient, one eye becomes larger than the other, it may not close at all when blinking and during sleep.
Raymond Sestan's disease 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, not daring to turn half of their torso.
Brissot syndrome distorts the facial muscles on the side of the facial nerve, there is a distortion of the pyramidal path. There is irritation of the cells of the roots or the nucleus of the facial nerve, reflex spasms appear in the opposite area of the lesion.

Brain peduncle lesions

Peduncular Syndromes:

Weber-Pobler disease develops on the basis of pathological processes in the area of \u200b\u200bthe legs of the brain, due to impaired hemorrhage of the ischemic type. And also when squeezing the legs with a developing tumor.
Clinical signs of the disease are paralysis of the muscles of the face, tongue and limbs according to the central type. Symptoms are due to a complete or partial cut of the oculomotor nerve. In case of muscle damage, the eyeball deviates towards the temple, and "looks" into reverse side paralyzed limbs. If the pathology also captures the optic tract, then hemianopsia occurs. The patient develops an enlarged strabismus, he sees poorly and hardly distinguishes colors. The phareic component, clonus of the hands and feet may also develop, and over time, violations of the flexion carpal protective reflexes will be observed.
Claude syndrome (red nucleus)- captures the fibers of the oculomotor nerve, due to damage to the branches of the posterior cerebral artery, which supplies lower divisions red core. common cause the onset of the disease are atherosclerosis and syphilitic endarteritis.

General picture of symptoms

There is a set of signs characteristic of all types of the syndrome:

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

The patient's diagnosis is established together with Benedict's and Weber's syndromes; an individual form of this type of alternating disease is very rarely manifested.

Benedict syndrome

Benedict syndrome (upper side of the red nucleus) - affects the nuclei of the oculomotor nerve, sometimes the medial loop. It is characterized by strabismus, mydriasis, eyelid trembling, hemiparesis.

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

Notnagel's pathology

Notnagel's disease (four-colonial) - occurs with extensive damage to the midbrain and its partial base. The main cause of the occurrence is a pituitary tumor, which, when expanded, compresses the red nuclei and the upper legs of the cerebellum.

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

A person does not speak well, his speech becomes slurred, it is difficult to pronounce consonants, and he also does not hear well or does not understand the speech of the interlocutor at all.

Arise and eye symptoms, there is bilateral ophthalmoplegia, medriz, ptosis. Visual impairment occurs gradually, pupillary reactions first 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 on the basis of unilateral damage to the brain stem in traumatic brain injuries, peripheral paralysis on the side of the lesion in combination with conduction disorders.

The clinical picture includes isolated or extensive paresis of the lateral 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 brain, characterized by loud noise in the ears, horizontal nystagmus in one direction, distortion of mimic 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 focus correspond to the zone of vascularization.

With a hemorrhage in the brain stem, symptoms may increase due to reactive edema, accompanied by respiratory disorders, cardiac activity, and vomiting.

IN acute period muscle tone decreases, certain facial features are distorted, speech changes, it becomes slurred and scattered.

Midbrain Syndromes

Symptoms include internal, external and total ophthalmoplegia, the patient's gaze down, converging strabismus. Discoordination of eye movements, the presence of limb paresis. As well as disorders of balance, hearing, vision, swallowing and speech functions.

The red core syndrome is manifested by symptoms of damage to the third pair of cranial nerves on the side of the focus.

It is noted, excessive reflex movements, with sharp sound irritations.

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

Signs of impaired activity of the brain bridge:

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, disorders in the work of the cardiovascular system.

Summary

In view of the many varieties of alternating syndromes, the main guarantee of their successful treatment is timely diagnosis and professional approach to therapy.

Modern technologies allow high precision determine the localization of the lesion and timely prevent its further development.

Alternating syndromes (Latin alterno to alternate; synonyms: alternating paralysis, cross paralysis) syndromes that combine damage to the cranial nerves on the side of the focus 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 Sekara 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 brainstem system. tumor processes with localization in the brain stem, traumatic brain injury. The most common stem symptom complexes are characterized by a lesion on the side of the focus of one or more cranial nerves along peripheral type(due to damage to their nuclei or roots), as well as conduction disorders on the opposite side (hemiparesis, hemiplegia, hemianesthesia, hemiataxy, etc.) due to damage to the fibers of the pyramidal pathway, medial loop, cerebellar connections, etc.

Allocate bulbar, pontine, peduncular and mixed alternating syndromes depending on the location of the focus (which is important to clarify the localization of damage).

Clinical picture of alternating syndromes

1. Bulbar alternating syndromes:

Jackson's syndrome (medial medullary syndrome, Dejerine's syndrome) occurs when the nucleus of the hypoglossal nerve and fibers of the pyramidal tract 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.

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.

Schmidt's syndrome is characterized by a combined lesion of the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and the pyramidal tract. It is manifested from the focus by paralysis of the soft palate, pharynx, vocal cord, half of the tongue, sternocleidomastoid and upper trapezius muscles, on the opposite side by hemiparesis and hemihypesthesia.

Wallenberg Zakharchenko's 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 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.

Babinski-Nageotte syndrome occurs when there is a combination of lesions of the inferior cerebellar peduncle, olivocerebellar tract, sympathetic fibers, pyramidal, spinothalamic tracts, and medial loop. It is characterized from the focus by the development of cerebellar disorders, Horner's syndrome, from the opposite side by hemiparesis, loss of sensitivity.

2. Pontine alternating syndromes:

Miyyar Gubler's syndrome (medial bridge syndrome) occurs when the nucleus or root of the facial nerve and the pyramidal tract are damaged. Manifested from the focus by paralysis of the facial nerve, on the opposite side by hemiparesis.

Fauville's syndrome (lateral bridge syndrome) is observed with a combined lesion of the nuclei (roots) of the abducens and facial nerves, the medial loop, and 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.

Raymond Sestan's syndrome is 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 by hemihypesthesia, sometimes by hemiparesis.

Brissot's 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.

3. Peduncular alternating syndromes:

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

Claude's syndrome (dorsal mesencephalic syndrome, lower red nucleus syndrome) occurs when the nucleus of the oculomotor nerve, superior cerebellar peduncle, and red nucleus are damaged. It is characterized on the side of the lesion by ptosis, divergent strabismus, mydriasis, on the opposite side by hemiparesis, hemiataxy or hemiasynergy.

Benedict's syndrome (upper red nucleus syndrome) is noted with damage to the nuclei of the oculomotor nerve, the red nucleus, the red nucleus-dentate fibers, and sometimes the medial loop. On the side of the focus, ptosis, divergent strabismus, mydriasis occur, on the opposite side, hemiataxia, eyelid trembling, hemiparesis (without Babinsky's symptom).

Notnagel's syndrome occurs with a combined lesion of the nuclei of the oculomotor nerves, the superior cerebellar peduncle, the lateral loop, the red nucleus, and the pyramidal pathway. On the side of the focus, ptosis, divergent strabismus, mydriasis are noted, on the opposite side, choreatetoid hyperkinesis, hemiplegia, paralysis of the muscles of the face and tongue.

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's syndrome occurs when thrombosis of the anterior spinal artery or its branches, Avellis and Schmidt syndromes develop when there is a violation of blood circulation in the branches of the artery that feeds 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 Fauville, Brissot, Raymond Sestan occur with damage to the branches of the basilar artery, peduncular syndromes of deep branches of the posterior cerebral artery, Claude's syndrome of the anterior and posterior arterioles of the red nucleus, Benedict's syndrome of the interpeduncular or central arteries etc.

The change in symptoms characterizes the cause of the pathological process. Ischemic lesion brainstem, for example, as a result of thrombosis of the branches of the vertebral, basilar or posterior cerebral artery leads to the gradual development of alternating syndromes, not even accompanied by loss of consciousness. The borders of the focus in this case correspond to the zone of circulatory disorders, hemiplegia or hemiparesis are spastic in nature. Hemorrhages in the brainstem can lead to the occurrence of atypical alternating syndromes. This is due to the fact that, in addition to the area of the damaged vascular pool, the surrounding brain tissues are also involved in the process due to the development peripheral edema. acute development The focus in the pontine zone is accompanied by respiratory disorders, cardiac activity, and vomiting. In the acute period, a decrease is determined muscle tone on the side of hemiplegia.

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 location of the lesion, it is 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 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). Damage to 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); absence of 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 dysfunction of the cranial nerves on the side of the lesion and central paralysis or paresis of the extremities 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 damage to 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 comprises 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 lesion), 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 there may be hyperkinesis (choreiform or athetoid), paresis or paralysis of the limbs, central paralysis VII and XII nerves. The syndrome is caused by a lesion of the midbrain tegmentum.

Alternating syndromes, characteristic of the intrastem process, can also occur during compression 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 temporal lobe or the pituitary region, may be manifested by damage to the oculomotor nerve (mydriasis, ptosis, exotropia, 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 area of the decussation pyramidal pathways, 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 medulla in the area of vascularization of the middle cerebral artery. Vertigohemiplegic syndrome with discirculation 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 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, reduced arterial pressure and there is a spasm of the facial muscles, 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 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 muscular hypotension as a result of diaschism.

Isolation of alternating syndromes helps the clinician in carrying out differential diagnosis for which the complex of all symptoms matters. With alternating syndromes caused by damage main vessels, shown surgery(thrombintimectomy, vascular plasty, etc.).