Alternating syndromes (Cross syndromes). Brain stem and alternating syndromes Pontine alternating syndromes

Alternating syndromes - dysfunction of the cranial nerves (III, YII, IX, X, XI, XII) and the cerebellum on the side of the lesion in combination with hemiparesis or hemihypesthesia on the opposite side - alternating syndromes or tetraparesis and internuclear ophthalmoplegia (damage to the brain stem).

Classification depends on the level at which the nuclei are affected:

  1. Bulbar (lesion at the level of the medulla oblongata):

- Jackson's syndrome is clinically manifested by a combination of peripheral paralysis of the hypoglossal nerve (XII) on the side of the brain lesion with spastic hemiplegia on the opposite side, in some cases, loss of musculo-articular and vibrational sensitivity. There may be dysarthria, paresis of the muscles of the larynx, swallowing disorders, cerebellar ataxia on the side of the focus. There is a deviation of the tongue in the direction of the lesion, atrophy and tuberosity of half of the tongue, fascicular twitches in it. A common cause of the development of the syndrome is thrombosis of the branches of a. spinalis anterior, so-called. aa. Sulci bulbaris.

Wallenberg-Zakharchenko syndrome (hypesthesia of the face, Horner's symptom (ptosis, miosis and enophthalmos), paresis of the muscles of the pharynx, cerebellar ataxia, weakness of the sternocleidomastoid and trapezius muscles on the side of the lesion and hemihypesthesia (without involving the face) on the opposite side (lateral infarction of the medulla oblongata)

2. Peduncular (damage at the level of the cerebellar peduncles):

  • Weber's syndrome is characterized by paralysis of the oculomotor nerve (III) on the side of the lesion, contralaterally - central hemiplegia or hemiparesis of the limbs and trunk, as well as central paresis of the facial (VII) and hyoid (XII) nerves. It is possible to attach hemianopsia when the lateral geniculate body is involved in the pathological process. Weber's syndrome is observed with damage to the base of the legs of the brain due to stenosis of the posterior cerebral artery and its branches, with syphilitic endarteritis, aneurysms of the posterior cerebral artery, with tumors, basal leptopachimeningitis. It is possible to localize a pathological process, for example, syphilitic gumma, in the meninges with subsequent spread to the brain stem.

3. Pontine (damage at the level of the bridge):

  • Fauville syndrome. In this syndrome, damage to the nuclei of the facial and abducens nerves (VII, VI) is observed with phenomena of peripheral paresis of the facial muscles and the external rectus muscle of the eye on the side of the lesion, as well as hemiparesis or hemiplegia of the central type on the opposite side. Characterized by convergent strabismus due to the eye on the side of the lesion. Occurs with obstruction of the circumferential branches of the main artery.
  • Miyyar-Gubler syndrome: defeat of the 7th pair of cranial nerves and the pyramidal tract.

Alternating syndromes

symptom complexes characterized by a combination of damage to the cranial nerves on the side of the focus with conduction disorders 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 A. s. can be caused by cerebrovascular accident, tumor, traumatic brain injury, etc.

The most common A. s. associated with lesions of the brain stem, manifested on the side of the focus by a violation of the function of the cranial nerves of the peripheral type (due to damage to their nuclei or roots) and conduction disorders on the opposite side (, hemiparesis, hemiataxia, etc. due to damage to the fibers pyramidal pathway, medial loop, spinothalamic pathway, cerebellar connections, etc.). To stem A. s. also applies to cross hemiplegia (of one arm and opposite leg), which occurs when there is a lesion in the area of ​​​​the intersection of the pyramidal tracts at the border of the medulla oblongata and spinal cord. Depending on the localization of the lesion in the brainstem, bulbar (a focus in the medulla oblongata), pontine (a bridge of the brain), and peduncular (a focus in the brain stem) are distinguished. There are A. pages associated with damage to several parts of the brain stem and extracerebral A. pages.

Alternating syndromes caused by unilateral damage to the sensory organs and various structures of the brain that have a common source of blood supply with them are called extracerebral A. s. As a rule, they occur in the pathology of one of the main vessels of the head and are associated with a secondary violation of circulation in the basin of its branches. In this case, several extra- and intracerebral lesions are formed in areas of impaired blood circulation.

Bulbar alternating syndromes. Jackson syndrome is caused by damage to the nucleus of the hypoglossal nerve and fibers of the pyramidal tract. On the side of the pathological focus, peripheral paralysis of the muscles of the tongue develops (deviation of the tongue towards the lesion, half of the tongue, sometimes fibrillar twitches in the tongue, degeneration when examining the electrical conductivity of the muscles of the tongue), on the opposite side - central hemiplegia or hemiparesis of the extremities.

Avellis syndrome occurs when the motor nucleus or motor roots of the glossopharyngeal and vagus nerves and the pyramidal tract are affected. On the side of the lesion, peripheral paralysis of the soft palate, uvula, vocal fold with impaired swallowing, phonation, speech () is detected, on the opposite side - central hemiplegia or hemiparesis.

Schmidt's syndrome is based on a combined lesion of the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and the pyramidal tract. On the side of the lesion, there is a peripheral soft palate, vocal cord, sternocleidomastoid and trapezius muscles, on the opposite side - central hemiplegia or hemiparesis.

The Babinski-Najotte syndrome is observed with a combination of damage to the inferior cerebellar peduncle, the olivocerebellar tract, sympathetic fibers, as well as the pyramidal tract, the spinothalamic tract, and the medial loop. On the side of the lesion, cerebellar disorders (hemiataxia, lateropulsion), Horner's syndrome are recorded (see Bernard-Horner's syndrome) , on the opposite side - central hemiplegia or hemiparesis, hemianesthesia.

Wallenberg-Zakharchenko syndrome is caused by damage to the motor nucleus of the vagus and glossopharyngeal nerves, the nucleus of the spinal tract of the trigeminal nerve, sympathetic fibers, the inferior cerebellar peduncle, the spinothalamic tract, and sometimes the pyramidal tract. On the side of the lesion, peripheral paralysis of the soft palate and vocal cord, a violation of superficial sensitivity on the face according to the segmental type, Horner's syndrome, ataxia are detected, on the opposite side - a violation of superficial sensitivity according to the hemitype, sometimes central hemiparesis.

Tapia syndrome occurs when there is a combination of damage to the nuclei or fibers of the accessory, hypoglossal nerves and the pyramidal tract. On the side of the pathological focus - peripheral paralysis of the sternocleidomastoid and trapezius muscles, muscles of the tongue, on the opposite side - central hemiplegia or hemiparesis.

Wolstein's syndrome is caused by damage to the oral motor nucleus of the glossopharyngeal and vagus nerves and the spinothalamic tract. On the side of the lesion - peripheral paralysis of the vocal fold, on the opposite side - hemianesthesia.

Pontine. Miyyard-Gubler syndrome is determined when the nucleus or root of the facial nerve and the pyramidal tract are affected. On the side of the lesion - unilateral peripheral paralysis of the mimic muscles, on the opposite side - central hemiplegia or hemiparesis.

Brissot-Sicard syndrome is caused by irritation of the nucleus of the facial nerve and damage to the pyramidal tract. On the side of the lesion - unilateral facial muscles, on the opposite side - central hemiplegia or hemiparesis.

Fauville's syndrome is observed with a combined lesion of the nuclei or roots of the facial and abducens nerves, the pyramidal tract, and the medial loop. On the side of the pathological focus - peripheral paralysis of the facial nerve, converging with the limitation of the movement of the eyeball outward, diplopia, on the opposite side - central hemiplegia or hemiparesis, hemianesthesia.

Raymond-Sestan syndrome is caused by a combined lesion of the posterior longitudinal fasciculus, the pontine center of gaze, the middle cerebellar peduncle, the medial loop, and the pyramidal pathway. On the side of the lesion - choreoathetoid, gaze paresis towards the focus, on the opposite side - central hemiplegia or hemiparesis, hemianesthesia.

Peduncular alternating syndromes. Weber's syndrome occurs when the nucleus or root of the oculomotor nerve and the fibers of the pyramidal tract are damaged. On the side of the pathological focus - divergent strabismus, on the opposite side - central hemiplegia; central paralysis of the muscles of the face and tongue is also possible.

Benedict's syndrome is caused by damage to the nucleus of the oculomotor nerve, the red nucleus, the red nucleus-dentate fibers, and sometimes the medial loop. On the side of the lesion - ptosis, divergent strabismus, mydriasis, on the opposite side - intentional, sometimes hemianesthesia.

Claude's syndrome is determined by damage to the nucleus of the oculomotor nerve, the superior cerebellar peduncle. On the side of the pathological focus - ptosis, divergent strabismus, mydriasis, on the opposite side - ataxia, dysmetria, decreased muscle tone.

Notnagel's syndrome is caused by a combined lesion of the nuclei of the oculomotor nerve, the superior cerebellar peduncle, the lateral loop, the red nucleus, and the fibers of the pyramidal tract. On the side of the lesion - ptosis, divergent strabismus, mydriasis, cerebellar ataxia (one and two-sided), on the opposite side - choreoathetoid hyperkinesis, central hemiplegia, central paralysis of the muscles of the face and tongue.

Alternating syndromes associated with damage to several parts of the brain stem. Glick syndrome is caused by damage to the optic, trigeminal, facial, vagus nerves and the pyramidal tract. On the side of the lesion - peripheral paralysis (paresis) of facial muscles with their spasm, in the supraorbital region, decreased vision or difficulty swallowing, on the opposite side - central hemiplegia or hemiparesis.

Cross hemianesthesia occurs when the nucleus of the spinal tract of the trigeminal nerve is damaged at the level of the pons 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 and limbs.

Extracerebral alternating syndromes. Opto-hemiplegic syndrome occurs with unilateral damage to the retina, optic nerve, motor area 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.

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

Asphygmohemiplegic syndrome (syndrome of the brachiocephalic arterial trunk) is observed 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 - spasm of mimic muscles, on the opposite side - central hemiplegia or hemiparesis. There is no common carotid artery on the affected side.

Topico-diagnostic value. Analysis of the symptoms of damage to the cranial nerves, sensory organs, conduction disorders in A. s. allows you to determine the localization and boundaries of the pathological focus. In clinical practice, A. s. can be observed with tumors of the brain stem and with disorders of cerebral circulation (brain). So, Jackson's syndrome occurs with thrombosis of the anterior spinal artery or its branches, Avellis and Schmidt syndromes - with circulatory disorders in the branches of the arteries that feed the medulla oblongata, and Wallenberg's syndrome - Zakharchenko, Babinsky - Najotte - in the basin of the inferior posterior cerebellar or vertebral artery, syndrome cross hemiplegia - with thrombosis of the spinobulbar arterioles. Pontine (bridge) syndromes of Fauville, Brissot - Sicard, Raymond - Sestan are detected when the branches of the basilar (main) artery are affected, peduncular syndromes - deep branches of the posterior cerebral artery, Claude's syndrome - anterior and posterior arterioles of the red nucleus, Benedict's syndrome - interpeduncular or central arteries and etc.

The dynamics of symptoms can be judged on the nature of the pathological process. So, with ischemic damage to the brain stem as a result of thrombosis of the branches of the vertebral, basilar or posterior cerebral arteries, A. s develop gradually, often without loss of consciousness; the boundaries of the focus correspond to the zone of impaired vascularization; hemiplegia or hemiparesis are spastic. At a hemorrhage in And. may be atypical, tk. the boundaries of the focus may not correspond to a specific vascular pool and may increase due to reactive cerebral edema around the focus of hemorrhage. Acute development of the focus in the bridge of the brain is accompanied by respiratory disorders, cardiac activity, vomiting. In the acute period, a decrease in muscle tone on the side of hemiplegia is determined as a result of diaschisis. .

Bibliography: Gusev E.I., Grechko V.E. and Burd G.S. Nervous diseases, p. 185, M., 1988; Krol M.B. and Fedorova E.A. Major neuropathological syndromes, p. 132, Moscow, 1966; Triumfov A.V. diseases of the nervous system, p. 148, L., 1974.


1. Small medical encyclopedia. - M.: Medical Encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic dictionary of medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

See what "Alternating Syndromes" is in other dictionaries:

    ALTERNATIVE SYNDROMES- ALTERNATE SYNDROMES, are such a set of neuropathological phenomena of loss of functions, when one of their parts is outwardly expressed on one half of the body (for example, in the form of right-sided paralysis or paresis of the limbs), and ... ...

    - (lat. alterno 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 ... ... Wikipedia

    Alternating syndromes- (Latin alter one of two syndromes) a group of neurological syndromes that occur when the nervous tissue is damaged in the brainstem area. At the same time, various combinations of paralysis and paresis of the cranial nerves and sensory disturbances are observed ...

    Alternating syndromes- (Greek alternus - cross) - signs of a unilateral lesion of the brain stem. On the side of the lesion, dysfunctions of one or more cranial nerves of the peripheral type are observed, on the other side - conduction ... ... Encyclopedic Dictionary of Psychology and Pedagogy

    Ponte Varoliyev's syndromes of defeat- a combination of central paresis or paralysis on the opposite side and symptoms of damage to the cranial nerves of the peripheral type on the side of the lesion. The symptom complexes that arise in this case are defined as alternating syndromes (lat. Encyclopedic Dictionary of Psychology and Pedagogy

    - (truncus encephali; synonymous with the brain stem) part of the base of the brain, containing the nuclei of the cranial nerves and vital centers (respiratory, vasomotor and a number of others). S. g. m. has a length of about 7 cm, consists of the midbrain, ... ... Medical Encyclopedia

    cerebellar-pontine angle- (Klein hirnbruckenwinkel, angle ponto cerebelleuse, for some eye angle ponto bulbo cerebelleuse) occupies a peculiar place in neuropathology, neurohistopathology and neurosurgery. This name denotes the angle between the cerebellum, oblong ... ... Big Medical Encyclopedia

    I Stroke Stroke (late Latin insultus attack) is an acute violation of cerebral circulation, causing the development of persistent (lasting more than 24 hours) focal neurological symptoms. During I. complex metabolic and ... ... Medical Encyclopedia

    BRAIN- BRAIN. Contents: Methods for studying the brain ..... . . 485 Phylogenetic and ontogenetic development of the brain ............... 489 Bee of the brain ............... 502 Anatomy of the brain Macroscopic and ... ... Big Medical Encyclopedia

    The ratio of the oculomotor nerve with the eyeball and other nerves ... Wikipedia

Je's syndromexona(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 language from the hearth ( language"looks" at the focus) and central hemiplegia or hemiparesis of the extremities on the opposite side.

Ave syndromelisa(palatopharyngeal paralysis) develops with damage to the nuclei of the glossopharyngeal and vagus nerves and the pyramidal pathway. It is characterized from the focus by paralysis soft palate and pharynx, on the opposite side - hemiparesis and hemihypesthesia.

Shmi syndromedta characterized by a combined lesion of the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and the pyramidal pathway. It manifests itself from the focus of paralysis of the soft palate, pharynx, vocal cord, half of the tongue, sternocleidomastoid and upper trapezius muscles, on the opposite side - hemiparesis and hemihypesthesia.

Va syndromellenberg-zahá rchenko(dorsolateral medullary syndrome) occurs when the motor nuclei of the vagus are damaged, trigeminal and glossopharyngeal nerves, sympathetic fibers, inferior cerebellar peduncle, spinothalamic tract, sometimes the 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 injured posterior inferior cerebellar artery.

Baby Syndromensky-najó tta 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 focus by the development of cerebellar disorders, Horner's syndrome, from the opposite side - hemiparesis, loss of sensitivity.

Pontine alternating syndromes

Miya syndromera-GuBlair(medial bridge syndrome) occurs when the nucleus or root of the facial nerve and the pyramidal tract are damaged. Manifested from the hearth paralysis facial nerve, on the opposite side - hemiparesis.

Fo syndromevilla(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 focus by paralysis abducens nerve and paralysis of gaze towards the focus, sometimes paralysis of the facial nerve; on the opposite side - hemiparesis and hemihypesthesia.

Ra syndromeymon-sé camp 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.

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 focus and hemiparesis on the opposite side.

Peduncular alternating syndromes

Be syndromebera(ventral mesencephalic syndrome) is observed with damage to the nucleus (root) of the oculomotor nerve and fibers of the pyramidal pathway. On the side of the lesion are marked ptosis, mydriasis, divergent strabismus, on the opposite side - hemiparesis.

Klo's syndromeYes(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.

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

Notn's syndromegel 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, on the opposite side - choreatetoid hyperkinesis, hemiplegia, paralysis of the muscles of the face and tongue

2. Extramedullary tumors.

The most common first symptom is radicular pain. Due to the predominant lesion of the posterior roots, the initial neurological symptom of an extramedullary neoplasm is a unilateral radicular symptom, followed by the addition of compressive myelopathy. Tumors located in the upper cervical region of the spinal cord can cause occipital headaches. Tumors at the level of the thoracic region often mimic symptoms similar to those of heart disease.

neurofibroma mainly develops from sensory nerve roots, manifesting as fusiform dilatation of the nerve, which makes it impossible to surgically separate this tumor from the nerve root without cutting the latter.

Schwannoma also usually develops from sensory nerve roots. In general, they are well demarcated from the nerve root and often have little association with a small number of fasciculae in the nerve root without fusiform thickening of the nerve itself. Thus, schwannomas can sometimes be removed without cutting the entire nerve.

Spinal meningiomas can occur at any age, but most often between the fifth and seventh decades of life. In 75-80% of cases, these tumors occur in women. It is assumed that meningiomas grow from arachnoid cells at the exit of nerve roots or entry of arteries, which explains their tendency to antero-lateral localization. Most often, these neoplasms are located in the thoracic region. Most thoracic meningiomas are localized along the posterior-lateral surface of the dural sac, while cervical meningiomas are more often located in the anterior half of the spinal canal.

Malignant intradural extramedullary tumors Most intradural extramedullary tumors are benign. Primary malignant intradural extramedullary nerve sheath tumors are most often a manifestation of Recklinghausen's disease (neurofibromatosis-I). In neurofibromatosis-I, there is an increased incidence of neurofibroma transforming into neurofibrosarcoma (also known as malignant schwannoma and neurogenic sarcoma). Pathological subtypes include malignant schwannomas, neurofibrosarcomas, malignant epithelioid schwannomas, and malignant melanocytic schwannomas. In addition, there are malignant meningiomas and meningeal fibrosarcomas.

3. Brain abscess- delimited accumulation of pus in the brain, which occurs secondarily in the presence of a focal infection outside the central nervous system; the simultaneous existence of several abscesses is possible. It can occur as a complication of skull injuries, often simulates a brain tumor, but has a more rapid development (within a few days or weeks).

Etiology and pathogenesis

The most common pathogens are streptococci, staphylococci, Escherichia coli, anaerobic bacteria, nocardia, fungi, toxoplasma (most often in HIV-infected), rarely develops with cysticercosis of the brain. 2 ways of spreading infection - contact and hematogenous:

Contact

    Otogenic abscesses (50% of cases) - the spread of infection with otitis media, mastoiditis. In this case, the abscess is located in the temporal lobe and cerebellum

    Due to purulent diseases of the paranasal sinuses (rhinogenic abscesses), pharynx, eye sockets, oral cavity

    Abscesses resulting from penetrating injuries of the skull, with osteomyelitis of the bones of the skull, subdural empyema

Hematogenous(result of bacteremia)

    Metastatic abscesses (source - pulmonary abscess, pneumonia, bronchiectasis, infective endocarditis, with CHD blue right-to-left reset type)

    Purulent diseases of the lungs - the second most common cause of abscesses (after otogenic abscesses)

    Failure to comply with aseptic conditions during intravenous administration of drugs

    The source of bacteremia cannot be detected in 20% of cases.

Stages: purulent encephalitis, formation of a cavity of necrotic decay, encapsulation.

Clinical picture

At the stage of encephalitis and the formation of a cavity of necrotic decay.

    General infectious - Intoxication (hyperthermia, chills are pronounced; the general serious condition of the patient).

    Cerebral (due to increased ICP)

    Meningeal syndrome (occurs when the meninges are irritated)

    Persistent diffuse headache - worse after exertion, often has a throbbing character

    Stiff neck

    Symptom Kernig - occurs often

    Symptoms Brudzinsky(upper, middle and lower)

    General skin hyperesthesia and increased sensitivity to light and sound stimuli.

    Violation of consciousness (up to stupor and coma), delirium, psychomotor agitation are possible.

    Hypertensive syndrome due to edema in and around the area of ​​inflammation (resulting in increased ICP)

    Diffuse intense headache of a bursting nature

    Nausea and vomiting at the height of the headache

    Dizziness

    Bradycardia

    Edema of the optic discs (examination of the fundus).

    By the time the abscess with a capsule is fully developed (after 4-6 weeks), general infectious symptoms usually subside, and the patient's condition improves. Subsequently, the following are preserved:

    Intracranial hypertension (additional volume due to the abscess itself), expressed slightly

    Focal symptoms - epileptic seizures, paralysis and sensitivity disorders of different localization, visual field disorders, aphasia.

Diagnostics

    CT or MRI is most informative (most patients receive treatment without bacteriological diagnosis)

    Lumbar puncture is contraindicated because it can cause transtentorial or temporal herniation. Bacteria are cultured in less than 10% of cases

    Search for the primary source of infection (X-ray of the chest, skull to detect fractures, sinusitis of various localization, etc.)

    Peripheral blood test - the number of leukocytes may be normal or slightly increased (good separation of the abscess from surrounding tissues). At an early stage - polynuclear leukocytosis, nuclear shift to the left, increased ESR

    Bacteriological examination of pus obtained by puncture of an abscess

    It is necessary to exclude a primary or metastatic brain tumor, subdural empyema, stroke, subacute or chronic meningitis, chronic subdural hematoma.

TREATMENT

Lead tactics. It is necessary to decide on the choice of treatment method - conservative or surgical. Surgical treatment is considered the only tactically correct method, although there are situations when one has to limit oneself only to medicinal effects. Surgical treatment is indicated for the formed abscess capsule (4-5 weeks after the first signs of the disease) and the threat of herniation (according to urgent indications). Percutaneous abscess drainage through a burr hole under CT guidance. If necessary, the procedure can be repeated. In the case of deeply located abscesses or abscesses of functionally significant areas, puncture aspiration followed by the introduction of antibacterial drugs is considered the only method of treatment. Craniotomy is used for large or multiple abscesses. Most often, an operation is performed to remove an abscess along with a formed capsule. The operation must be supplemented with massive doses of antibiotics.

Alternating syndromes(lat. alterno- 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

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, tumor processes localized in the brainstem, and traumatic brain injury. Stem symptom complexes, which are most common, are characterized by lesions on the side of the focus of one or more cranial nerves of the 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 fibers of the pyramidal tract, 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).

Bulbar alternating syndromes

Jackson syndrome(medial medullary syndrome, Dejerine's syndrome) is observed with a half lesion of the lower part of the medulla oblongata, and is characterized by a combination of peripheral paralysis of the hypoglossal nerve and central hemiparesis of the extremities on the opposite side. Peripheral paralysis of the hypoglossal nerve: atrophy of the same half of the tongue (thinning and folding of the mucous membrane), fascicular twitching. When protruding, the tongue deviates towards the lesion of the nucleus or nerve. Standard: when the left genio-lingual muscle is contracted, the tongue is pushed forward and to the right, when the right is contracted, vice versa. If the right nerve is affected, then with the contraction of the left genio-lingual muscle, the tongue is pushed to the right (to the side of the lesion).

Avellis syndrome(Palatopharyngeal paralysis) develops with damage to the nuclei of the glossopharyngeal, vagus and hypoglossal nerves and the pyramidal tract. It is characterized from the side of the focus by paralysis of the soft palate and pharynx.

Schmidt syndrome characterized by a combined lesion of the motor nuclei or fibers of the glossopharyngeal, vagus, accessory nerves and the pyramidal pathway. It manifests itself from the focus of paralysis of the soft palate, pharynx, vocal cord, half of the tongue, sternocleidomastoid and upper part of the trapezius muscle.

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, the occurrence of perverted temperature sensitivity. Occurs when the posterior inferior cerebellar artery is damaged.

Babinski-Najotte syndrome occurs with a combined lesion 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 of cerebellar disorders, Horner's syndrome.

Pontine alternating syndromes

Miyar-Gubler syndrome(medial bridge syndrome) occurs when the nucleus or fibers of the 7th pair and the pyramidal path are damaged. On the side of the focus - peripheral paralysis of the mimic muscles: the face is asymmetrical, the muscles of the healthy half pull the skin of the face to their side, the racket symptom, the absence of nasolabial and frontal folds, the weakness of the mimic muscles of the upper and lower floors (atrophy, hypotrophy, hypotension, hyporeflexia, fibrillation and fasciculations ). Lagophthalmos (incomplete closure of the palpebral fissure due to paralysis of the circular muscle of the eye); symptom of eyelashes (when you try to close your eyes, the eyelashes remain in sight); Bell's phenomenon - when you try to close your eyes, the eyeballs run up. There are no autonomic disorders (taste is normal, lacrimation, salivation and swallowing reflex are normal. Dysacusia. On the opposite side - central hemiparesis or hemiplegia.

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 - central hemiparesis or hemiplegia.

Raymond-Sestan syndrome noted with damage to the posterior longitudinal bundle, middle cerebellar peduncle, medial loop, pyramidal pathway. It is characterized by paralysis of gaze towards the focus.

Brissot syndrome occurs when the nucleus of the facial nerve is irritated and the pyramidal tract is damaged. It is characterized by facial hemispasm from the focus.

Gasperini syndrome occurs when the pons operculum is damaged and is characterized by a combination of damage to the auditory, facial, abducent and trigeminal nerves on the side of the pathological focus.

Peduncular alternating syndromes

Weber syndrome(ventral mesencephalic syndrome) there is damage to the nuclei and roots of the third pair of cranial nerves (oculomotor nerve) and the pyramidal pathway. On the side of the lesion: ptosis, mydriasis, divergent strabismus, diplopia, disturbance of accommodation, exophthalmos. On the opposite side: central hemiparesis, paresis of the muscles of the face and tongue, and hemihypesthesia.

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. Ptosis, divergent strabismus, mydriasis occur on the side of the lesion, and intentional tremor and choreoform (rubral) hyperkinesis occur on the opposite side.

Benedict syndrome noted with damage to the nuclei of the oculomotor nerve, the red nucleus, red-nuclear-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, 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.

Central hemiparesis of the extremities

A generalized description of the changes that occur on the opposite side, with alternating syndromes, regardless of the location of the lesion.

On the opposite side: spastic hypertonicity, with a predominance of the phasic component, is characterized by the “jackknife” phenomenon, the Wernicke-Mann posture, clonus of the feet and hands, hyperreflexia and expansion of reflexogenic zones, the appearance of pathological reflexes (on the hand - Rossolimo, Zhukovsky, Bekhterev; on the foot - Babinsky, Rossolimo). Pathological synkinesias (global [accompanying massive movements (coughing, sneezing), involuntary movements of the paralyzed limb are observed]); coordinating [involuntary friendly movements in the paralyzed limb when performing voluntary movements in healthy muscles functionally associated with paralyzed ones]; imitation [the paralyzed limb involuntarily repeats the movement healthy, although the same movement cannot be voluntarily performed.] Pronounced protective reflexes: shortening protective reflex;

Diagnostics

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 disturbed in the branches of the artery that feeds the medulla oblongata, and Wallenberg-Zakharchenko and Babinski-Najotte syndromes develop in the basin of the inferior posterior cerebellar or vertebral artery. Pontine syndromes of Fauville, Brissot, Raymond-Sestan occur when the branches of the basilar artery are affected, peduncular syndromes - deep branches of the posterior cerebral artery, Claude's syndrome - the anterior and posterior arterioles of the red nucleus, Benedict's syndrome - the interpeduncular or central arteries, etc.

The change in symptoms characterizes the cause of the pathological process. Ischemic damage to the brain stem, for example, as a result of thrombosis of the branches of the vertebral, basilar or posterior cerebral arteries, 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 of peripheral edema. Acute development of the focus in the pontine zone is accompanied by respiratory disorders, cardiac activity, and vomiting. In the acute period, a decrease in muscle tone on the side of hemiplegia is determined.

These are syndromes that accompany unilateral focal lesions of the brain stem, the general scheme of which includes damage to the nuclei of the cranial nerves on the side of the focus and contralateral conduction (motor and sensory) disorders. Depending on the level of localization of the lesion, bulbar (medulla oblongata), pontine (pons varolii) and penduncular (midbrain, brain stems) alternating syndromes are distinguished.

Alternating syndromes of the medulla oblongata.

Jackson syndrome (peripheral paralysis of the hypoglossal nerve on the side of the brain lesion; spastic hemiplegia on the opposite side; loss of musculo-articular and vibration sensitivity; dysarthria; paresis of the muscles of the larynx; swallowing disorders; cerebellar ataxia on the side of the focus; deviation of the tongue towards the lesion, atrophy and tuberosity of half of the tongue, fascicular twitching in it). Cause - branch thrombosis a. spinalis anterior.

Avellis syndrome (paralysis of the soft palate and vocal cords; atrophic changes in the tongue on the affected side; contralateral spastic hemiplegia; hemianesthesia; swallowing disorders; dysarthria; dysphonia). The reason is the defeat of the branches a. fossae lateralis bulbi.

Schmidt's syndrome (peripheral paresis of the entire caudal group of cranial nerves - 9,10,11,12; contralateral hemiparesis and hemianesthesia; unilateral paralysis of the soft palate and vocal cord; atrophy of the tongue, sternocleidomastoid and trapezius muscles).

Babinsky-Najotte syndrome (cerebellar disorders on the side of the focus - hemiasynergy and lateropulsion; nystagmus and sympathetic disorders on the face; narrowing of the palpebral fissure, enophthalmos - Bernard-Horner syndrome; on the opposite side - hemiparesis, pain and temperature hemianesthesia). The focus is usually located on the border of the medulla oblongata and the pons.

Wallenberg-Zakharchenko syndrome (on the side of the lesion - paralysis of the soft palate and vocal muscle; sensitivity disorder on the face of a segmental type; Bernard-Horner syndrome; on the opposite side - hemianesthesia by conduction type, less often hemiplegia; with extensive foci - respiratory and cardiac disorders - vascular activity).

Alternating pontine syndromes.

Miyyar-Gubler syndrome (peripheral paresis of the facial nerve on the side of the lesion; central hemiparesis or hemiplegia of opposite limbs). Occurs when the pathological focus is localized at the base of the bridge.

Brissot-Sicard syndrome (irritation of the nucleus of the facial nerve with the development of tonic and clonic convulsions in the muscles of the face on the side of the lesion; hemiparesis or hemiplegia on the opposite side). It is based on a violation of blood circulation in the main artery or its branches.

Fauville's syndrome (peripheral paresis of the facial muscles and the external rectus muscle of the eye on the side of the lesion; hemiparesis or hemiplegia in the central type on the opposite side; converging strabismus due to the eye on the side of the lesion). It is based on a violation of blood circulation in the main artery or its branches.

Gasperini's syndrome (peripheral paralysis of the facial and efferent nerves, motor portion of the trigeminal nerve; decreased sensitivity on the face; hearing loss on the side of the lesion; nystagmus in the direction opposite to the lesion; Bernard-Horner's syndrome; conduction-type hemihypesthesia on the contralateral half of the trunk and extremities) . The reason is a violation of blood circulation in the basin of the anterior inferior cerebellar artery.

Raymond-Sestan syndrome (cerebellar disorders on the side of the focus - homolateral asynergy, gaze paralysis towards the focus, contralateral hemiplegia and hemianesthesia; hyperkinesis). The reason is a violation of blood circulation in the main artery or its branches, as well as tumors.

Alternating peduncular syndromes.

Weber's syndrome (paralysis of the oculomotor nerve on the side of the lesion; contralateral - central hemiplegia or hemiparesis of the limbs and trunk; central paresis of the facial and hypoglossal nerves; hemianopsia). It is observed with damage to the base of the legs of the brain due to stenosis of the posterior cerebral artery and its branches, with syphilitic endarteritis, aneurysm of the posterior cerebral artery, with tumors, basal leptopachimeningitis.

Benedict's syndrome (on the side of the lesion - paresis of the oculomotor nerve; contralateral - intentional trembling in the limbs and choreoathetosis; hemianesthesia). It develops when the red nucleus is damaged. Occurs with thrombosis and hemorrhage in the branches of the posterior cerebral artery and with cancer metastasis.

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