Alternating syndromes — the neurologic violations including unilateral damage of cranial nerves and counterlateral to it motive and/or touch frustration. A variety of forms is caused by various level of defeat. Diagnostics is performed clinically during neurologic inspection. For establishment of an etiology of a disease MRT of a brain, a research of cerebral haemo dynamics, the analysis of a likvor is carried out. Treatment depends on genesis of pathology, includes conservative, surgical ways, recovery therapy.
Alternating syndromes received the name from the Latin adjective "alternance" meaning "opposite". The concept includes the simptomokompleks which are characterized by signs of damage of the craniocereberal nerves (CN) in combination with central motive (paresis) and sensitive (gipesteziya) violations in an opposite half of a body. As paresis covers extremities of a half of a body, it carries the name a hemiparesis ("gem" – a half), similarly touch frustration are designated by the term a gemigipesteziya. Because of a typical clinical picture alternating syndromes in neurology have a synonym "cross syndromes".
Reasons of alternating syndromes
The characteristic cross neurologic symptomatology arises at half defeat of a cerebral trunk. Pathological processes can be the cornerstone:
- Stroke. The most frequent reason causing alternating syndromes. The thrombembolia, a spasm in system of a vertebral, bazilyarny, brain artery becomes Etiofaktor of an ischemic stroke. The hemorrhagic stroke arises at hemorrhage from the specified arterial vessels.
- Brain tumor. Alternating syndromes appear at direct defeat of a trunk a tumor, at a sdavleniye of stem structures the row increasing in sizes the located new growth.
- Inflammatory processes: encephalitis, meningoentsefalita, abscesses of a brain of a variable etiology with localization of the inflammatory center in stem fabrics.
- Craniocereberal trauma. In some cases fractures of the bones of a skull forming a back cranial pole are followed by alternating symptomatology.
Alternating simptomokompleks of extra stem localization are diagnosed at violations of blood circulation in an average brain, general or internal carotid.
Kernels of cranial nerves are located in various departments of a cerebral trunk. There passes the motive path (a pyramidal way) bearing an efferent impulsation from cerebral bark to neurons of a spinal cord, the sensitive highway which is carrying out afferent touch impulses from receptors, cerebellar ways. The motive and sensitive carrying-out fibers at the level of a spinal cord form a recross. As a result the innervation of a half of a body is carried out by the nervous ways passing in an opposite part of a trunk. Unilateral stem defeat with simultaneous involvement in pathological process of kernels of ChMN and the carrying-out highways clinically is shown by the cross symptomatology characterizing alternating syndromes. Besides, cross symptoms arise at simultaneous defeat of motive bark and an extra stem part of ChMN. Pathology of a midbrain differs in bilateral character, does not lead to alternating symptomatology.
On an arrangement of the center of defeat allocate extra stem and stem syndromes. The last are subdivided on:
- — are connected by Bulbarnye with focal damage of a medulla where kernels of the IX-XII cranial nerves, the lower legs of a cerebellum are located.
- Pontinnye — are caused by the pathological center at the level of the bridge with involvement of kernels of the IV-VII nerves.
- Pedunkulyarnye — arise at localization of pathological changes in brain legs where red kernels, the top cerebellar legs settle down, there pass backs of the III couple of ChMN, pyramidal paths.
Clinic of alternating syndromes
The basis of a clinical picture is made by alternating neurologic symptoms: symptoms of dysfunction of ChMN on the party of defeat, touch and/or motive frustration from the opposite side. Damage of nerves has peripheral character that is shown by a hypotone, an atrophy, fibrillations of the innervated muscles. Motive violations represent the central spastic hemiparesis with a hyper reflection, pathological-foot signs. Depending on an etiology alternating symptoms have sudden or gradual development, are followed by all-brain symptomatology, symptoms of intoxication, intra cranial hypertensia.
Jackson's syndrome is formed at defeat of a kernel of the XII (hypoglossal) nerve and pyramidal ways. It is shown by peripheral paralysis of a half of language: put out tongue deviirut towards defeat, the atrophy, fastsikulyation, difficulties of a pronunciation of difficult articulated words is noted. In counterlateral extremities the hemiparesis, sometimes — loss of deep sensitivity is observed.
Avellis's syndrome is characterized by paresis of muscles of a throat, throat, vocal chords owing to dysfunction of kernels yazykoglotochny (IX) and wandering (X) nerves. The popyorkhivaniye, violations of a voice (dysphonia), speeches (dizartriya) with a hemiparesis, a gemigipesteziya of opposite extremities is clinically observed. Defeat of kernels of all kaudalny ChMN (the IX-XII couple) causes Schmidt's option different from the previous form paresis - clavicular and mastoidal and trapezoid muscles of a neck. From the struck party omission of a shoulder is observed, restriction of raising of a hand is higher than horizontal level. The turn of the head towards paretichny extremities is complicated.
Babinsky-Nazhotta's form includes a cerebellar ataxy, , Horner's triad, is cross — paresis and disorder of superficial sensitivity. At Wallenberg-Sachartschenko's option the similar clinic, dysfunction IX, X and V nerves comes to light. Can proceed without paresis of extremities.
Miyyara-Gyubler's syndrome appears at pathology in the field of a kernel of the VII couple and fibers of a pyramidal path, represents a combination of front paresis to a hemiparesis of the opposite side. The similar localization of the center which is followed by irritation of a kernel of a nerve causes Brisso-Sikar's form at which instead of front paresis it is observed front . Fovill's option differs in existence of peripheral paresis of the VI cranial nerve giving clinic of the meeting squint.
Gasperini's syndrome — defeat of kernels of the V-VIII couples and a sensitive path. Front paresis, the meeting squint, a gipesteziya of the person, relative deafness is noted, it is possible . Kontrlateralno is observed a gemigipesteziya on conduction type, motility is not broken. Raymond-Sestana's form is caused by defeat of motor and touch ways, an average cerebellar leg. The dyssynergia, a diskoordination, a gipermetriya are found on the party of the center, a hemiparesis and a gemianesteziya — kontrlateralno.
Weber's syndrome — dysfunction of a kernel of the III couple. It is shown by omission of a century, expansion of a pupil, turn of an eyeball towards an external corner of an eye, a cross hemiparesis or a gemigipesteziya. Distribution of pathological changes on a cranked body adds visual violations (gemianopsiya) to the specified symptomatology. Benedict's option — pathology of a glazodvigatelny nerve is combined with dysfunction of a red kernel that is clinically shown by an intentsionny tremor, atetozy opposite extremities. Sometimes is followed by a gemianesteziya. At Notnagel's option glazodvigatelny dysfunction, a cerebellar ataxy, disorders of hearing, a counterlateral hemiparesis is observed, giperkineza are possible.
Extra stem alternating syndromes
Haemo dynamic violations in system of a subclavial artery cause emergence of a vertigogemiplegichesky form: symptoms of dysfunction of a vestibulo-cochlear nerve (noise in an ear, dizziness, hearing falling) and a cross hemiparesis. The Optikogemiplegichesky option develops at a distsirkulyation at the same time in an orbital and average brain artery. It is characterized by a combination of dysfunction of an optic nerve and a cross hemiparesis. The Asfigmogemiplegichesky syndrome arises at carotid occlusion. It is observed opposite to a hemiparesis face muscles. The Patognomonichny sign — lack of a pulsation of sleepy and beam arteries.
The alternating syndromes which are followed by a spastic hemiparesis lead to development of contractures of the joints aggravating motor frustration. Paresis of the VII couple causes a distortion of the face who becomes a serious esthetic problem. The relative deafness reaching full loss of hearing is result of damage of an acoustical nerve. Unilateral paresis of glazodvigatelny group (III, VI couples) is followed by doubling (diplopiya) significantly worsening visual function. The most terrible complications arise when progressing defeat of a brain trunk, its distribution on the second half and the vital centers (respiratory, cardiovascular).
Survey of the neurologist allows to establish existence and a type of a cross syndrome. The obtained data give the chance to define the topichesky diagnosis, that is localization of pathological process. Approximately it is possible to judge an etiology on a course of disease. Tumoral processes differ in progrediyentny increase of symptomatology within several months, sometimes — days. Inflammatory defeats often are followed by all-infectious symptoms (temperature increase of a body, intoxication). At a stroke alternating symptoms arise suddenly, quickly accrue, proceed against the background of changes of arterial pressure. The hemorrhagic stroke differs from ischemic in an indistinct atypical picture of a syndrome that is caused by lack of a clear boundary of the pathological center in connection with the expressed perifokalny processes (swelled, the jet phenomena).
For establishment of the cause of neurologic symptomatology additional researches are conducted:
- Brain MRT. Allows to visualize the inflammatory center, a hematoma, a trunk tumor, area of a stroke, to differentiate a hemorrhagic and ischemic stroke, to define degree of a sdavleniye of stem structures.
- TKDG of cerebral vessels. The most available, rather informative method of diagnostics of violations of a cerebral blood-groove. Finds symptoms of a thrombembolia, a local spasm of intracerebral vessels.
- UZDG of ekstrakranialny vessels. It is necessary in diagnostics of occlusion of sleepy, vertebral arteries.
- MRT of vessels of a brain. The most informative way of diagnostics of sharp violations of brain blood circulation. Visualization of vessels helps to diagnose precisely character, localization, extent of their defeat.
- Research of tserebrospinalny liquid. The Lyumbalny puncture is carried out at suspicion on the infectious and inflammatory nature of pathology in favor of which inflammatory changes of a likvor testify (a turbidity, at the expense of neutrophils, existence of bacteria). Bacteriological and virologic researches allow to reveal the activator.
Treatment of alternating syndromes
Therapy is carried out concerning the main disease, includes conservative, neurosurgical, rehabilitation methods.
- Conservative therapy. Purpose of antiedematous, neurotyre-tread means, correction HELL belongs to the general actions. The differentiated treatment is performed according to a disease etiology. The ischemic stroke is the indication to thrombolytic, vascular therapy, hemorrhagic — to purpose of medicines of calcium, aminokapron to - you, infectious defeats — to performing antibacterial, antiviral, antimikotichesky therapy.
- Neurosurgical treatment. Can be required at a hemorrhagic stroke, defeat krovosnabzhayushchy a brain of the main arteries, volume educations. According to indications reconstruction of a vertebral artery, a carotid endarterektomiya, formation extra- an anastomoz, removal of a tumor of a trunk, removal of a metastatic tumor and so forth is carried out. The issue of expediency of surgical intervention is resolved together with the neurosurgeon.
- Rehabilitation. It is carried out by joint efforts of a reabilitolog, the doctor of LFK, the massage therapist. It is directed to the prevention of contractures, increase in volume of the movement of paretichny extremities, adaptation of the patient to the state, postoperative restoration.
Forecast and prevention
According to an etiology alternating syndromes can have various outcome. The hemiparesis leads to an invalidization of most of patients, the complete recovery is observed in rare instances. Limited ischemic strokes in case of quickly begun adequate treatment have more favorable forecast. Recovering from a hemorrhagic stroke less full and longer, than after ischemic. Predictively tumoral processes, especially metastatic genesis are difficult. Prevention is not specific, consists in timely effective treatment of tserebrovaskulyarny pathology, the prevention of neuroinfections, ChMT, onkogenny influences.