Signs of damage to the right hemisphere of the brain. Disturbances of higher mental functions with damage to the right hemisphere of the brain (an example from practice) Features of damage to the right and left hemisphere gnosis

The topic of strokes has recently become more than relevant. According to statistics, every 90 seconds one of the residents of Russia experiences a stroke with different locations anatomically and, as a result, different consequences and prognosis physiologically. There is a dependence of the incidence of the disease on race, nature of work (mental or physical), age and lifestyle. Today, stroke ranks second as a cause of death according to WHO. The first place belongs to IHD (by the way, also a vascular disease). The third one is cancer.

Strokes are the scourge of modern society

What is a stroke?

A stroke is a sudden blockage of blood circulation to the brain. There can be several mechanisms for the development of this condition: blockage or compression of a vessel, or rupture of a vessel with the ensuing consequences.

If there is a violation of the integrity of the vessel, then a hemorrhagic stroke is implied. When the blood flow in the vessels of the brain is disrupted due to a blood clot or compression (for example, a tumor or hematoma), the diagnosis is ischemic stroke. The mechanism of development of the disease is very similar to a heart attack (most often, vascular thrombosis is the cause of both stroke and heart attack). Only in the first case everything happens in the vessels of the brain, and in the second - in the coronary arteries (heart vessels). We can say that a stroke is a cerebral infarction, in which there is also an area of ​​necrosis due to metabolic disorders and hypoxia of surrounding tissues.

It is known that one of the most important tasks of blood is the delivery of oxygen to organs and tissues. During a stroke, blood abruptly stops flowing to the brain tissue; due to lack of oxygen, large areas of nerve cells suffer and die, with corresponding consequences for the patient.

To understand the seriousness of the condition and the mechanism of the process, you need to know that each part of the brain is responsible for a specific function(s). Depending on the location and volume of damaged tissue, the performance of one or another function is affected.

Risk factors

Some risk factors cannot be influenced (race, gender, heredity, age, season, climate).

It is quite possible to correct other risk factors to prevent the possibility of a stroke and its consequences. For example, physical inactivity, obesity, stressful situations, arterial hypertension, lipid metabolism disorders, diabetes mellitus, alcohol consumption and smoking.

Symptoms

It is also known from biology lessons at school that a person has two hemispheres of the brain: the left and right hemispheres. In this case, the left side of the brain controls the right side of the body, and vice versa. That is, if a patient has paresis of the left upper limb, for example, then the source of damage is in the right side of the brain.

How to recognize a stroke?

Symptoms or consequences can be divided into general for strokes, regardless of the cause (blockage, compression or rupture), localization (right or left) and focal (characteristic of damage to a specific area of ​​the brain). It is also possible for a stroke to be extensive (a large part of the brain is damaged) or focal (a small area of ​​the brain is damaged). Common symptoms will be headache that comes on suddenly, dizziness, nausea, tinnitus, loss of consciousness, tachycardia, sweating, feeling hot, depression.

A characteristic feature, and at the same time a problem for recognizing a stroke in the right hemisphere, is the absence of speech impairments (in contrast to symptoms with damage to the left hemisphere of the brain).

Therefore, in cases of right-sided stroke with mild symptoms, people rarely seek treatment. medical care in the first days of illness, when you can significantly influence the outcome of the disease by preventing consequences.

It must be said that the picture of this condition is bleak, since the recovery period is complicated by neuropsychopathological syndromes that usually occur in the patient. Complete restoration of lost functions is possible with minor lesions in the right hemisphere of the brain.

In case of a major stroke, after treatment, a successful prognosis is given if the patient can care for himself. As a rule, the consequences of such a stroke are disability, although there are exceptions to any rule.

When an extensive stroke is localized in the right hemisphere, spatial disorientation occurs, and the ability to objectively assess the shape and size of objects (including one’s own body in space and time) is lost. The patient's left visual field disappears, that is, what healthy people see with peripheral vision (on the left), a patient with a right-sided stroke does not see. The focal symptoms of a right-sided stroke are paresis or paralysis of the limbs on the left; amnesia for recent events, drooping down the left corner of the mouth; spatial disorientation. In left-handed people, the consequences of a stroke may be impaired speech function.

Facial distortion during stroke

The emotional sphere suffers, behavior changes: it becomes inappropriate, inadequate, swagger appears, tact and correctness are absent. The difficulty in treatment and the likelihood of lack of effect when the right hemisphere is involved is very high, since patients are not aware of their condition, do not understand the danger and are not committed to recovery. Patients have no perception of reality. Such patients do not understand that they have problems with the ability to move, there may even be a feeling that there are many limbs, not two, so treatment can be very problematic.

However, right-hemisphere strokes in right-handed people are more common favorable prognosis to restore motor and cognitive functions, in contrast to damage to the left hemisphere, associated with significant speech and intellectual-mnestic impairments.

Treatment and rehabilitation

During these difficult periods, you will need the support and understanding of family and friends.

It is necessary for doctors to stop the acute condition. At the same time, it is necessary to influence all possible links in pathogenesis. Therefore, antiplatelet agents, anticoagulants, enzymes and neuroprotectors are necessarily included in the treatment regimen. Treatment should take place in a hospital under the supervision of a doctor. The prognosis depends on the location of the lesion - in the right or left hemisphere, the extent of the process, concomitant diseases, the patient’s focus on recovery and the severity of the consequences.

A set of special exercises is selected individually for each patient

Rehabilitation measures must be comprehensive. The sooner treatment and rehabilitation are started, the greater the chance for the patient to return decent quality life and prevent consequences. At the same time, medications are continued, exercise therapy, massage, and physiotherapy are prescribed.

Doctors' prognoses for a major stroke of any location are disappointing; you need to be prepared for serious consequences; the possibility of coma cannot be ruled out. But the chances of survival are enormous proper treatment and care.

Prevention

Prevention of strokes consists of monitoring and correcting factors that can provoke a vascular accident. In case of arterial hypertension, it is necessary to take medications that maintain blood pressure at the required level. Must be excluded bad habits, stressful situations. As part of drug support, it is possible to use antiplatelet agents - blood thinning drugs; as well as cerebroprotectors and drugs that improve microcirculation. It is important to lead an active lifestyle, while controlling psycho-emotional stress.

Comprehensive stroke prevention

Ischemic stroke is not an independent, sudden condition, but a consequence of some process, therefore the key to successful prevention is the timely detection and prevention of such consequences and processes.

Some clinical manifestations of organic brain diseases are specific to damage to one or the other hemisphere. When involved in a pathological process left hemisphere Right-handers, as a rule, develop aphasic disorders, agraphia, acalculia, and alexia. Localization of the outbreak in right hemisphere manifested by emotional disturbances (euphoria or depression), hallucinations, amusia. A characteristic feature The right hemisphere focus is an apratic-agnostic syndrome, which consists of the patient’s uncritical attitude towards his condition, anosognosia, a violation of the body diagram, and the absence of an active attitude towards recovery. Often, lesions of the right hemisphere in acute brain lesions (stroke, trauma) are accompanied by so-called parakinesis, or automated gestures, i.e., automatic, unconscious movements of the limbs homolateral to the pathological focus.

Pathology of the autonomic nervous system

BASIC FUNCTIONS

Based on anatomical and functional data, the nervous system is usually divided into somatic, or animal, responsible for the connection of the body with the external environment, and vegetative, or plant, regulating the physiological processes of the internal environment of the body, ensuring its constancy and adequate reactions to the influence of the external environment. The autonomic nervous system is in charge of the energy, trophic, adaptive and common functions of animal and plant organisms. protective functions. In the aspect of evolutionary vegetology, it is a complex biosystem that provides conditions for maintaining the existence and development of an organism as an independent individual and adapting it to the environment.

The autonomic nervous system functions “with the indispensable participation of exogenous factors, which are completely naturally included in its functional structure” (G.I. Markelov). It innervates not only internal organs, but also sensory organs and the muscular system. Research by L. A. Orbeli and his school, the doctrine of the adaptive-trophic role of the sympathetic nervous system showed that the autonomic and somatic nervous systems are in constant interaction. In the body they are so closely intertwined that it is sometimes impossible to separate them. This can be seen in the pupillary reaction to light. The perception and transmission of light stimulation is carried out by the somatic (optic) nerve, and the constriction of the pupil is due to the autonomic, parasympathetic fibers of the oculomotor nerve. Through the optical-vegetative system, light exerts its direct effect through the eye on the autonomic centers of the hypothalamus and pituitary gland (i.e., we can talk not only about the visual, but also about the photovegetative function of the eye).

As noted above, the anatomical difference in the structure of the autonomic nervous system is that the nerve fibers do not go from the spinal cord or the corresponding nucleus of the cranial nerve directly to the working organ, like somatic ones, but are interrupted in the nodes of the sympathetic trunk and other nodes of the autonomic nervous system. Due to the fact that the preganglionic fibers of a certain segment are highly branched and end at several nodes, a diffuse response is created when one or more preganglionic fibers are stimulated.

Reflex arcs of the sympathetic division of the autonomic nervous system can close both in the spinal cord and in these nodes (47).

An important difference between the autonomic nervous system and the somatic nervous system is the structure of the fibers. Autonomic nerve fibers belong to type B and C fibers, they are thinner than somatic ones, covered with a thin myelin sheath or without it at all (non-myelinized or non-myelinated fibers). Conduction of impulses through such fibers occurs much more slowly than through somatic fibers: on average, 0.4-0.5 m/s for sympathetic fibers and 10.0-20.0 m/s for parasympathetic fibers. Several fibers can be surrounded by one neurilemma (Schwann membrane), so excitation through them can be transmitted via a cable type, i.e., an excitation wave traveling through one fiber can be transmitted to fibers that are currently at rest.

As a result, diffuse excitation along many nerve fibers arrives at the final destination of the nerve impulse. Direct impulse transmission through direct contact of unmyelinated fibers is also allowed.

The main biological function of the autonomic nervous system - trophoenergetic - is divided into histotropic, trophic - to maintain a certain structure of organs and tissues, and ergotropic - to develop their optimal activity.

If the trophotropic function is aimed at maintaining the dynamic constancy of the internal environment of the body (its physicochemical, biochemical, enzymatic, humoral and other constants), then the ergotropic function is aimed at vegetative-metabolic support of various forms of adaptive purposeful behavior (mental and physical activity, the implementation of biological motivations - food, sexual, motivations of fear and aggression, adaptation to changing environmental conditions).

The autonomic nervous system realizes its functions mainly in the following ways: 1) regional changes in vascular tone; 2) adaptive-trophic effect; 3) function management internal organs.

As is known, on the basis of morphological, as well as functional and pharmacological characteristics, the autonomic nervous system is divided into the sympathetic, predominantly mobilized during the implementation of the ergotropic function, and the parasympathetic, more aimed at maintaining homeostatic balance - the trophotropic function.

These two parts of the autonomic nervous system, functioning mostly antagonistically, provide, as a rule, double innervation bodies.

The parasympathetic division of the autonomic nervous system is more ancient. It regulates the activities of organs responsible for the standard properties of the internal environment. The sympathetic department develops later. It changes the standard conditions of the internal environment and organs in relation to the functions they perform. This adaptive significance of sympathetic innervation and its change in the functional capacity of organs was established by I. P. Pavlov. The sympathetic nervous system inhibits anabolic processes and activates catabolic ones, while the parasympathetic nervous system, on the contrary, stimulates anabolic processes and inhibits catabolic processes.

The sympathetic division of the autonomic nervous system is widely represented in all organs. Therefore, processes in various organs and systems of the body are reflected in the sympathetic nervous system. Its function also depends on the central nervous system, endocrine system, processes occurring in the periphery and in the visceral sphere, and therefore its tone is unstable, according to

mobile, requires constant adaptive-compensatory reactions.

The parasympathetic department is more autonomous and is not as closely dependent on the central nervous and endocrine systems as the sympathetic one. It is worth mentioning the functional predominance at a certain time of one or another part of the autonomic nervous system, associated with the general biological exogenous rhythm, during the day, for example, the sympathetic, at night - the parasympathetic. In general, the functioning of the autonomic nervous system is characterized by periodicity, which is associated, in particular, with seasonal changes in nutrition, the amount of vitamins entering the body, as well as light stimulation (due to the participation of the opto-vegetative, or photoenergetic, system in the periodicity of most processes occurring in the body).

Changes in the functions of organs innervated by the autonomic nervous system can be achieved by irritating the nerve fibers of this system, as well as by the action of certain chemicals. Some of them (choline, acetylcholine, physostigmine) reproduce parasympathetic effects, others (norepinephrine, mesatone, adrenaline, ephedrine) - sympathetic ones. Substances of the first group are called parasympathomimetics, and substances of the second group are called sympathomimetics. Acetylcholine is a transmitter released in all intermediate ganglia of the autonomic nervous system and in postganglionic parasympathetic fibers. Postganglionic sympathetic fibers release norepinephrine, which affects alpha-adrenergic receptors, and adrenaline, which affects beta-adrenergic receptors. In this regard, the parasympathetic autonomic nervous system is also called cholinergic, and the sympathetic - adrenergic. Different substances affect different parts of the autonomic nervous system: nicotine and tetraethyl ammonium block the connection between prenodal fibers and nodes, ergotamine paralyzes postganglionic sympathetic fibers, and atropine and scopolamine paralyze postganglionic parasympathetic nerve fibers.

In the implementation of specific functions of the autonomic nervous system, its synapses are of great importance.

The functional specificity of the internal organs is determined by the organ receiving the nerve impulse, i.e., by the chemical specificity of a particular tissue that realizes synaptic excitation, and not by the specific characteristics of certain autonomic fibers. Thus, if you cut the parasympathetic fibers of the chorda tympani and to the distal end If you sew up the phrenic nerve, then after regeneration it will function like a drum string.

The autonomic function includes, in particular, the act of urination. The spinal center of sympathetic innervation of the bladder is located in the lateral horns of La, Ls-1.4 segments of the spinal cord, and parasympathetic 82-84. Sympathetic fibers traveling to the bladder through the inferior hypogastric plexus and vesical nerves cause contraction of the internal sphincter and relaxation of the m. detrusor urinae (urine displacer). Increased tone of the sympathetic nervous system leads to urinary retention. Parasympathetic fibers travel to the bladder through the pelvic nerve. They relax the sphincter and contract m. detrusor urinae. Increased tone of the parasympathetic system leads to urinary incontinence. The muscles of the anterior abdominal wall and diaphragm take part in the act of urination. Suprasegmental control of urination is carried out by a complex system represented in various parts of the brain stem, basal ganglia, limbic system and cortex. The cortical urination center, which ensures the voluntary act of urination, is located in the paracentral lobule. Efferent fibers to special urination centers pass in the internal sections of the pyramidal tracts. Afferentation of the bladder is provided by the spinothalamic tracts and dorsal columns.

The autonomic system is closely connected with the endocrine glands, on the one hand, it innervates the endocrine glands and regulates their activity, on the other hand, hormones secreted by the endocrine glands have a regulatory effect on the tone of the autonomic nervous system. Therefore, it is more correct to talk about a unified neurohumoral regulation of the body. Adrenal medulla hormone (adrenaline) and thyroid hormone (thyroidin) stimulate the sympathetic autonomic nervous system. The hormone of the pancreas (insulin), hormones of the adrenal cortex, as well as the hormone of the thymus gland (during the period of growth of the body) stimulate the parasympathetic department. Hormones of the pituitary gland and gonads have a stimulating effect on both parts of the autonomic nervous system. The activity of the autonomic nervous system also depends on the concentration of enzymes and vitamins in the blood and tissue fluids.

The hypothalamus is closely connected with the pituitary gland, the neurosecretory cells of which send neurosecretion to the posterior lobe of the pituitary gland. In the overall integration of physiological processes carried out by the autonomic nervous system, of particular importance are the constant and reciprocal relationships between the sympathetic and parasympathetic systems, the functions of interoreceptors (in particular vascular reflexogenic zones), humoral autonomic reflexes and the interaction of the autonomic nervous system with the endocrine system and the somatic system, especially with its highest section is the cerebral cortex.

N. N. Bragina, T. A. Dobrokhotova

Syndromes and their clinical characteristics

PAROXYSMAL
The main symptom is paroxysmal occurrence. These states arise suddenly and quickly end.

Right hemisphere

Hallucinatory
False perceptions of something that is not in reality. Visual, tactile, auditory, olfactory, and taste hallucinations are possible. Auditory is expressed in imaginary rhythmic sounds - musical melodies, natural noises - birdsong, the sound of the surf. Olfactory and gustatory hallucinations, which usually occur when the deep parts of the temporal lobe of the right hemisphere are damaged, are unpleasant and painful in nature.

Derealization
The perception of the surrounding world is changed, devoid of reality. Patients may experience various sensations of this change: a different coloring of the world than it actually is; greater brightness of light than usual from past experience; distortions of spatial outlines, contours, sizes, shapes of objects (sometimes different in size, architectural design of houses and other buildings appear similar, not different from each other). An extreme version of derealization can be considered a feeling of immobility, deadness, soundlessness of the world, when everything moving (including surrounding people) is perceived by the patient as immobilized.

Symptom of “already seen”
An instantaneous feeling that the unfolding real situation is “already experienced,” “already seen,” “already heard,” although a similar situation did not exist in past memories.

"Never Seen"
The feeling is the opposite of the previous one. A situation that is well known, seen and experienced many times is perceived by the patient as “unfamiliar”, “never seen”, alien.

"Time Stop"
Instant feeling that time has “stopped”. This feeling is usually combined with an extreme version of the manifestation of derealization. Colors in the patient's perception become dull; three-dimensional, three-dimensional objects - flat, two-dimensional. At the same time, the patient perceives himself as if he has lost contact with the outside world and the people around him.

"Time Stretch"
In the patient’s sensations, time is experienced as “stretching”, longer than he is accustomed to from past experience. This sensation is sometimes combined with opposite (compared to the previous phenomenon) changes in the perception of the whole world. What is flat and two-dimensional appears to be three-dimensional, “alive, moving,” and gray-white is colored. The patient usually becomes relaxed, complacent or euphoric.

"Losing the sense of time"
A feeling revealed to the patient in other expressions: “as if there was no time,” “freed from the oppression of time.” This is always accompanied by a changed perception of the whole world. Objects and people seem more contrasting and, in the emotional perception of patients, “more pleasant.”

"Time Slow"
Feeling like time is “moving more slowly.” The perception of the whole world, the movements of people and objects changes. People appear to be “puppet-like, lifeless,” their speech is “official.” Patients call time “slow” on the basis that people’s movements are perceived as slow and their faces are perceived as “sullen.”

"Time Acceleration"
The feeling is the opposite of the previous one. To the patient, time seems to flow more quickly than he was accustomed to from past perceptions. In the patient’s perception, the whole the world around us and one's own "I". The world seems “unnatural”, “unreal”, people are perceived as “fussy”, moving very quickly. They feel their body worse than usual. The time of day and duration of events are determined with errors.

"Reverse Flow of Time"
A feeling that is specified by patients in the following expressions: “time is flowing downwards”, “time is going backwards”, “I am going back in time”. The surrounding world and the patient’s own “I” are perceived as changed. What is interesting is the gross fallacy of reproducing the remoteness of already experienced events; a second or a minute ago events that took place are perceived as having happened “a long time ago”

Palinopsia
Also referred to as “visual perseveration”. This phenomenon is close to the previous one. The situation, which is already absent in reality, seems to linger in the patient’s field of vision. In patients, this phenomenon can be combined with impairment of the left visual field, decrease or loss of topographic memory.

Depersonalization
Within the framework of depersonalization syndrome, described various options altered perception of one’s own “I”. The somatic or mental self may be perceived as altered; combinations of both are possible.

Somatic depersonalization
Occurs more often. It is expressed in an experience or sensation of one’s own body or its various parts that is different from what the patient is accustomed to from past perceptions. The whole body feels worse or only the left parts of it. At maximum severity, the patient ignores (not perceives) the left parts of the body, often the arm; the patient does not use his left hand, even if the weakness in it is insignificant. Sometimes the feeling of body integrity is disrupted; it (or its individual parts) “increases” or “decreases.” A feeling of multiplicity is possible, for example, the patient imagines that he has not one (left) hand, but several hands; at the same time, the patient often turns out to be unable to distinguish among them his own - the one that actually exists.

Mental depersonalization
It is expressed in a changed experience of one’s “I”, one’s personality, relationships with others, emotional contact with people. Patients say that they lose their senses, lose contact with all the people around them, using the phrase: “I go into another space, but everything remains in this space”, “I become an outside observer”, without “any feelings” I look at what “happens in this space.”

Total depersonalization
It includes changes in the perception of both the somatic and mental “I”, which seem to be regained when the patient recovers from the attack. The simultaneous occurrence of sensations of “foreignness” of one’s own voice, “physical splitting of the body into the smallest particles”, splitting of the mental “I” are described: “all parts of the body exist at this time as if independently and have their own “I”, in addition to the common “I”.

Two-track experience
A condition when the patient continues to perceive the surrounding reality; sometimes only what is on the patient’s right is perceived. In this case, a second stream of experiences arises in the form of involuntary revival, as if replaying in the consciousness of a specific period of time. In his consciousness, the patient is given, as it were, simultaneously in two worlds: in the real now world and in the world that was in the patient’s past tense. The patient identifies himself in consciousness, on the one hand, with how he is now and here (in present time and space), and on the other hand, as he was in a specific period of past time.

"Flash of Experience"
A state in which the patient ceases to perceive what exists in reality (in the objective present time and real space) and in his consciousness, as it were, returns entirely to some segment of the past time. In the patient’s consciousness, all the events that happened in that past are played out again, and they are experienced by the patient in the true sequence. The patient perceives himself as he was in that period of past time.
Oneiroid
This refers to a short-term transient oneiric state. The patient ceases to perceive himself and the world around him as they are in objective time and space. In the consciousness of the patient, he experiences a seemingly different, unreal world, more often a world of fantastic events (flights into space, meetings with aliens). In the retrospective (after recovery from the attack) description of the patient, the other world looks devoid of spatio-temporal supports. At the moment of experiencing oneiroid, the patient often experiences a feeling of weightlessness. It is close to “gravitational illusions,” described as the subjective experience of a change in the mass of one’s own body, which is explained by the activation in the cerebral cortex of those engrams in which the acquired experience is imprinted subjective feelings with short-term changes in body weight.

Emotional and Affective Disturbance Syndrome
There are three possible violations:
a) attacks of melancholy, fear or horror (with temporal localization of the lesion), combined with viscero-vegetative disorders, olfactory and gustatory hallucinations;
b) euphoria with relaxation (with damage to the parieto-occipital regions);
c) a state of unemotionality - a transient interruption of affective tone (with temporo-parietal-occipital lesions), often combined with the phenomena of derealization and depersonalization.

Left hemisphere

Hallucinatory
The most common are auditory and verbal hallucinations. Patients hear voices calling them by name or telling them something. Hallucinations can be multiple: the patient hears many voices at once, but cannot make out the content of what these voices are saying.

Speech disorder syndromes
Transient (motor, sensory, amnestic) aphasias that come on suddenly and quickly end. Such transient speech disturbances at the time of an attack occur in patients more often at a time when no changes in speech are observed outside the paroxysms.

Thinking disorders
More often, two conditions that are opposite to each other occur:
a) “thought gaps” - a feeling of emptiness in the head, as if “the formation of thoughts has stopped”; outwardly at the time of the attack, the patient looks anxious, confused, with an expression of bewilderment on his face;
b) “violent thoughts”, “surges of thoughts”, “whirlwind of thoughts” - a feeling of sudden appearance in the mind of thoughts that are not related in content to current mental activity; sometimes quickly, “like lightning,” a lot of thoughts appear, “interfering with each other,” “these thoughts make your head swell”; not a single thought is completed, has no complete content; these thoughts are experienced with a tinge of burdensomeness, violence, involuntariness - the impossibility of freeing oneself from them until the attack is over.

Memory disorders
There are two extreme options:
a) “memory failure” – helplessness, inability to remember the right words, the names of loved ones, even your age, place of work, is accompanied by confusion and anxiety;
b) “forced memory” - a painfully painful feeling of the need to remember something, but at the same time the awareness of what exactly is being remembered remains unattainable; This inaccessibility of awareness of the subject of the memory is combined with an anxious feeling, the fear that something “is about to happen” to the patient.

Absence
Turning off the patient from conscious mental activity in which he was engaged before the attack. The position in which the patient experienced the attack is preserved. All signs of attention in the patient’s appearance disappear; the gaze becomes motionless, the face becomes “stony”. It lasts a moment and the interlocutor can take a forced, natural pose. The patient himself does not remember what happened; An absence seizure usually results in complete amnesia. For a long time attacks may not be noticed by the patient himself or those around him. They become obvious as they become more complex due to the addition of speech and other phenomena.

Psychomotor seizures
Lasts minutes, hours, rarely – several days. While going into an attack, the patient continues to be active. Performs a variety of actions, sometimes complex and consistent psychomotor activity. These seizures differ from twilight states of consciousness in their lack of purposefulness and less sequence of actions: patients rush to run somewhere, begin to move extremely heavy objects from their place. Actions and actions are accompanied by shouts, usually meaningless. The patient's behavior becomes orderly only upon recovery from an attack, which is followed by amnesia.

Twilight disorder of consciousness
A sudden onset and suddenly ending state of altered consciousness, which is characterized by the implementation of complex sequential psychomotor activity, ending socially significant result, as well as amnesia for an attack. Conventionally, two options can be distinguished:
a) being in a twilight state of consciousness, patients continue to implement the program that was in consciousness before the onset of this state;
b) falling into a twilight state of consciousness, patients commit actions and deeds that were never in their intentions, alien to their personal attitudes; these actions are determined by psychopathological experiences - hallucinatory, delusional, which arise along with the onset of an altered state of consciousness. The first option coincides with a condition known as ambulatory automatism. With the second option, malice, irritation, anger, and aggressiveness are possible.

Syndrome of emotional, affective disorders
Many of the paroxysmal states listed above (transient aphasia, violent thoughts and memories, etc.), as a rule, are accompanied by an affect of anxiety and confusion. Independent paroxysms are possible, during which patients experience an affect of anxiety; At this point they become fussy, restless, and impatient. They express fears: “something is going to happen to me.” These concerns are always directed towards the future.

NON-PAROXYSMAL

Right hemisphere

Confabulatory confusion
A disturbance of consciousness in which the patient is disoriented in space and time so that the present reality is perceived as if through the content of past time. This is expressed in abundant confabulations: as events that just happened (in the hospital), the patient names events that happened sometime in the past and in some other place (at work, at home, etc.). Patients do not remember anything that happens and may be restless motorly. The words “here” and “now” are meaningless for them.

Korsakov's syndrome
The syndrome necessarily includes disorientation in space and time. Sometimes the patient is disoriented regarding his own personality; amnesia – fixation, retroanterograde; confabulation (in response to a question, for example, about what the patient did in the morning, he can name events that took place many years ago); false recognitions (in the surrounding faces the patient “recognizes” the faces of his loved ones and calls them by the names of these people); emotional and personal changes (patients are relaxed, complacent or even euphoric, verbose, exhibit anosognosia and, while the complete helplessness of the patients is obvious to everyone around them, they consider themselves healthy); disorders of the perception of space and time (for example, in the morning, patients can say that it is already evening; they err on the side of prolongation in determining the duration of events). Korsakoff's syndrome is often associated with left-sided hemiparesis, hemianesthesia, hemianopsia, and left space neglect.

Left-sided spatial agnosia
It is characterized by a cessation of perception (ignoring) of events that occur to the left of the patient. All stimuli are ignored by the patient: visual, auditory, tactile. Patients feel their body poorly or do not perceive it at all, most often this applies to the left parts, especially the left hand. They ignore the left side of the text when reading, the left side of the paper when drawing, etc. Patients are euphoric and relaxed; anosognosia is detected.

sad depression
Characterized by melancholy, motor and ideational retardation. This triad of symptoms usually occurs when the temporal part of the right hemisphere is damaged. The patient is inactive, speaks quietly, slowly; the face froze in one position.

Pseudological
Patients tend to mention or even describe in detail events that happened to them that did not actually take place. As a rule, patients do not derive any benefit from such pseudological statements. Patients are usually talkative and complacent, quickly coming into contact with people around them.

Emotional and personal changes
The most common and pronounced tendency is towards the predominance of a complacent or euphoric mood, inadequate to the patient’s condition and its severity. Criticism is decreasing. Often, lack of awareness and denial of one’s illness and the painfulness of the condition is anosognosia. Sometimes euphoria is combined to a pronounced degree with motor activity up to disinhibition; patients are cheerful, talkative, mobile, although they may exhibit left-sided hemiplegia, blindness and other signs of deep incompetence.

Sleep and dream disorders
Frequent indications from patients about an increase in the number of dreams: “I feel like I’ve been dreaming all night.” Sometimes colored dreams are noted. Patients often note that it is difficult for them to distinguish what happened in a dream from what happened in reality. Some patients experience stereotypical repetitions of the same dream.

Recurrent psychosis
Reminiscent of MDP, where conditions reminiscent of hypomania and depression are periodically repeated. They are distinguished by greater expression not of the emotional component itself, but by greater activity; in “good” condition, patients are highly active, productive, and sleep little; in “bad” conditions – lethargic, drowsy, tired.

Left hemisphere

Dysmnestic
At the center of the syndrome is a weakening of verbal memory. The patient forgets words, names, phone numbers, actions, intentions, etc. Forgetting does not reach the point of impossibility of reproducing the necessary information. The patient has an understanding of the defect and an active desire for compensation. They keep notebooks and write down everything that needs to be remembered.

Anxious depression
Characterized by anxiety and motor restlessness, confusion. Patients seem to be in a continuous search for motor rest; change position, stand up, sit down and get up again. They sigh, look around in bewilderment, and peer into the face of their interlocutor. They express fears that something is going to happen to them.

Delusional syndrome
At the center of the syndrome is a disorder of thinking with errors of judgment that cannot be corrected. Patients become more and more suspicious, distrustful, and anxious. They suspect others of having an unfriendly attitude towards them, of an intention to cause harm (to poison, disfigure, or have a bad influence on them). Externally the patient is tense. Sometimes he refuses food and medicine.

Speech changes
Even before the onset of aphasia, there may be speech aspontaneity with a lack of motivation for speech activity, or slips of the tongue may become increasingly common, when patients replace one word with another and do not notice it themselves. Speech becomes less and less detailed and monosyllabic.

Sleep and dream disorders
There is a decrease in dreams. Sometimes patients note the disappearance of dreams as one of the signs of changes in their sleep and dreams.

Emotional and personality changes
With damage to the frontal regions, patients are less and less proactive and aspontaneous; temporal - more and more anxious, tense, confused; There appears to be an increase in the vigilance of the patients, they are constantly mobilized. When the posterior parts of the left hemisphere are affected, a painful tone usually predominates in the mood of patients.

TABLE OF SYNDROMES ARISING DURING SELECTIVE
LESIONS TO THE RIGHT AND LEFT HEMISPHERES OF THE BRAIN (IN RIGHT-HANDED PEOPLE)

© N. N. Bragina, T. A. Dobrokhotova

9.1. Violation of perceptual functions with damage to the left and right hemispheres of the brain and with damage to the median structures

In the above-mentioned examination of children aged 6-16 years, conducted by E. G. Simernitskaya (see Chapter 8), along with an analysis of speech disorders in the same children, a study was carried out of the state of perceptual processes with lesions of the left and right hemispheres of the brain and with lesions of the median structures.

It has been shown that with damage to the left hemisphere, the most pronounced disturbances of visual gnosis are observed during the perception of crossed out and superimposed images (Poppelreiter figures). Lesions of the right hemisphere were accompanied by equally pronounced difficulties in visual perception of realistic images and Poppelreiter figures. Damage to the midline structures (diencephalic-hypothalamic region) led to greater difficulties in perceiving realistic images.

9.1.1. Impairment of perceptual functions due to damage to the left hemisphere of the brain

Visual disturbances with damage to the left hemisphere have a low frequency.

The maximum frequency of violations (in 29% of cases) was observed during the recognition of object images and was associated with damage to the occipital region of the left hemisphere.

These violations arose when it was necessary to identify and correlate several leading features of an object. The children did not rely on the entire set of features when perceiving the image; they singled out one and made guesses based on it. For example, a telephone was recognized as a clock, a table lamp as a mushroom.

The most pronounced violations of objective visual gnosis occurred during the perception of crossed out and superimposed images. They manifested themselves in difficulties in distinguishing a figure from the background, as a result of which only individual elements of the image were correctly assessed. For example, a hammer was recognized as a stick, a lily of the valley - twigs and leaves, a butterfly - a bat.

In visual-constructive activity (making drawings), mild disturbances were also observed. In children younger age they were not detected at all even with damage to the parietal region. With age (after 10 years), the severity of pattern disturbances became increasingly higher.

In older children, the drawings were primitive and simplified. Spatial errors were also recorded when drawing three-dimensional figures.

With damage to the left hemisphere, the characteristic feature was the preservation of a graphic image, which was usually reproduced correctly.

In general, pattern disturbances were more often observed with lesions in the parietal region.

In older children school age with damage to the left hemisphere, disturbances in visual-spatial functions were observed (in tests of spatial praxis, copying with reversal, in tests of a clock and a map, etc.).

However, the frequency of their occurrence was low and when they were detected, the nature of these disorders corresponded to those disorders that occur in adults. These disorders, as in adults, were associated with projective or coordinate representations.

It can be assumed that the low frequency of manifestations of disturbances in the perceptual sphere with damage to the left hemisphere is of the same nature as the low frequency of speech disorders. The left-hemisphere components of perceptual activity, which are associated with speech mediation of perceptual processes, are not yet sufficiently formed, which is due to the ongoing formation of the speech system.

9.1.2. Impairment of perceptual functions due to damage to the right hemisphere of the brain

Early lesions of the right hemisphere, which appeared in the first year of life, lead to gross underdevelopment of those functions for which the right hemisphere is dominant (visuospatial perception, visual-constructive and other types of perceptual activity).

When the right hemisphere is damaged in children, disturbances in perceptual processes appear, as a rule, selectively. Often they arise only in the sphere of facial gnosis. Patients do not recognize their own

5-58 relatives, and in less severe cases they complain of poor memory for faces. Just as in adults, these disorders arose with damage to the right occipital region.

As with lesions of the left hemisphere, children with lesions of the right hemisphere showed a violation of object gnosis, but it was of a different nature. In this case, the errors were of the opposite nature: the mushroom was recognized as a table lamp, the clock as a telephone. This indicates the different nature of these violations. When the left hemisphere is damaged, due to a deficiency in the process of sequential analysis of all the features of an object, the details of the picture, it is typical to ignore individual elements of the image - a telephone handset, wires. In the case of damage to the right hemisphere, difficulties in perceiving the perceived object are compensated by analyzing possible options for the image (what could it be?) and, based on a guess, the object is, as it were, supplemented with “missing details.” Therefore, when the right hemisphere is damaged, the errors are very diverse: for example, a ball is recognized as a tomato, an omelette, a watermelon, etc., a coat is recognized as a house without a window, a glass is recognized as a washing machine.

Violations of subject gnosis occurred more often with damage to the right hemisphere than with damage to the left hemisphere.

The same disturbances were also found in the perception of crossed out figures (Poppelreiter). But if, with damage to the left hemisphere, difficulties in this task were more pronounced (to a greater extent than when perceiving actually depicted objects), then with any damage to the right hemisphere there were no differences in the perception of figures when presented with each of these two tests. The errors were also of a different nature. With damage to the left hemisphere, each individual fragment of the image was perceived adequately, but its correlation with other features was disrupted, and this led to recognition based on an incomplete set of features. In the case of damage to the right hemisphere, on the contrary, difficulties in perceiving individual fragments were compensated by the emergence of side, random semantic connections that were not focused on the leading feature: jug - bread; butterfly - ribbon, pear, turnip, etc. This led to recognition focused on a redundant set of features that went beyond the image.

Thus, disturbances in object perception with damage to the right and left hemispheres were of a qualitatively different nature, due to the specific mechanisms of information processing in the left and right hemispheres - successive and simultaneous, respectively.

Lesions of the right hemisphere were also clearly manifested in the phenomenon of “left-sided inattention” - ignoring stimuli located in the left half of the visual field. This violation could manifest itself in the form of ignoring all stimuli located in the left half of the visual field; in other cases, the complete image disintegrated, and a conclusion about it was made on the basis of only signs located on the right. More often than not, only the extreme left elements were ignored.

Violations of color perception were recorded in isolated cases.

There were no impairments in animal recognition (in the presence of facial agnosia).

Disturbances in perceptual processes with damage to the right hemisphere were clearly manifested in the sphere of spatial representations, manifesting themselves in difficulties in spatial orientation.

In visual-constructive activity, when making drawings, disturbances were often in the nature of a gross defect, which was never observed with lesions of the left hemisphere.

This was most clearly evident when drawing three-dimensional figures. Often there was a disintegration of not only spatial representations, but also visual images in general.

A distinctive feature of right-hemisphere disorders (as opposed to left-hemisphere disorders) was that these disorders were not compensated for by copying.

Violation of the pattern occurred in 47% of cases and was maximally manifested in cases of damage to the right parietal region.

With damage to the right hemisphere, disturbances in topological ideas about an object occur (which does not happen with damage to the left hemisphere), as well as disturbances in ideas about the movement and transformation of an object.

At the same time, a comparison of disturbances in spatial representations in children and adults reveals some differences. They manifest themselves in the fact that childhood the right hemisphere provides a wider range of spatial representations than in adults. For example, when the right hemisphere is damaged in children, both projective ideas and ideas about the coordinate system suffer (in adults, such disorders are observed only when the left hemisphere is damaged). In children, similar disorders occur equally with damage to both the left and right hemispheres.

In general, we can talk about the leading role of the right hemisphere in perceptual processes, which manifests itself already in childhood.

The absence of special differences in these disorders in children of primary and senior school age indicates that the dominance of the right hemisphere in perceptual processes occurs early.

9.1.3. Disturbance of perceptual processes with damage to the median structures

As noted above, damage to the hypothalamic-diencephalic region of the brain has traditionally been associated with a disruption of ascending activating influences, which led to changes in the normal functioning of the cortex.

Neuropsychological studies have shown that suffering in this area of ​​the brain leads not only to disturbances in the verbal non-sensical sphere (pathological inhibition of traces by interfering influences, which were described above), but also to disturbances in the perceptual sphere.

Violations of objective gnosis come to the forefront here, which appear especially clearly when perceiving realistic images. This is a qualitative difference between symptoms of disorders in this area from symptoms characteristic of damage to the left hemisphere (in this case, the perception of Poppelreiter figures suffers more than the perception of realistic images), and from symptoms of damage to the right hemisphere (in this case, the perception of realistic and schematic images suffers approximately equally ).

Just as with impaired auditory-verbal memory, perceptual impairments were more common with intracerebral lesions (in the region of the 3rd ventricle) than with extracerebral tumors.

The frequency and severity of disturbances in the perceptual sphere with damage to the hypothalamic-diencephalic region significantly exceed the same disturbances with damage to the left hemisphere and practically do not differ from right-hemispheric lesions.

Most often, these disorders occurred before the age of 10 years, and to a lesser extent after 10 years.

A distinctive feature of visual perception disorders was that they were most clearly manifested when perceiving images of “living” objects (in particular animals). In general, in childhood, impairments in the recognition of animal images are detected regardless of object and facial agnosia. This may indicate that these perceptions of these objects have different brain organizations.

For example, mistakes were typical when: a dog is recognized as a horse or a cow; hare - like a kitten, cat; chicken is like fish; a frog is like an owl. Such errors are extremely rare in hemispheric disorders, as a rule, only in cases where the pathological process in the hemispheres also affected the median structures.

Another important symptom- violation of color gnosis (17.7% of cases).

Often coloring does not make it easier, but rather complicates the process of identifying an object. For example, orange orange recognizable as watermelon, cabbage; green watermelon - like orange, tomato.

Presenting colors outside the object increases the difficulty of their identification. The largest number of errors was in the perception of green, which was perceived as red, brown, yellow, gray, black. There were many errors in the perception of red, pink, and orange colors.

A characteristic feature was that errors could vary both among different patients and within one patient upon repeated presentation of stimuli.

Violation of color gnosis was detected mainly when naming colors, while the choice of a given color was available. When classifying color objects, errors occurred in distinguishing between red and green stimuli and attempts to place them in one group.

As E. G. Simernitskaya notes, the identified violations of color gnosis do not fit into the picture of congenital color anomalies, which are accompanied by a certain type of error. The variability of errors, the absence of color aphasia, and the isolated manifestation of this disorder indicate that the disturbance of color perception in children with damage to the midline structures has a different structure than that described in adults with damage to the left or right hemisphere.

In its manifestations, this disorder is most similar to the symptom of “anomia”, which is part of the “split brain” syndrome, when interhemispheric interaction between the structures that perceive visual information and which provide its verbal designation is disrupted. This usually occurs when the posterior parts of the corpus callosum are cut or damaged, that is, when interhemispheric connections are disrupted. But damage to the hypothalamic-diencephalic region does not lead to disorders of the corpus callosum. Only the anterior commissure is adjacent to this area, which plays important role in interhemispheric transfer in animals.

It can be assumed that in the early stages of ontogenesis it is the anterior commissure that performs the function of such transfer. E. G. Simernitskaya (1985) gives examples that may testify in favor of this hypothesis.

In the first case, patient S., 12 years old, was operated on for a tumor of the third ventricle affecting the optic nerves and chiasm. He had a sharp decrease in vision in the left eye, as well as bitemporal hemianopsia. This led to the fact that perception remained intact only from the left half of the visual field in the right eye, from where information is transmitted, respectively, to the right hemisphere. Scheme of disturbances in the processing of visual information resulting from organic brain damage in patient S.

Acute ischemic disorders of cerebral circulation are characterized by etiological heterogeneity: the main causes of ischemic stroke are atherosclerotic damage to the main arteries of the head (30-40%), hypertensive changes in blood vessels with the development of lacunar strokes (25-30%) or cardiogenic embolism in cardiovascular pathology (20 -25%). Other causes of cerebral infarction are hemorheological disorders, vasculitis and coagulopathies - 10% of cases, as well as unknown causes of strokes.

Signs of right hemisphere cerebral infarction

Ischemic stroke with localization of the lesion in the right hemisphere of the brain manifests itself:

• paralysis of the left side of the body;
• various disturbances of perception and sensation (there is a loss of the ability to assess the size and shape of objects with a violation of the perception of the diagram of one’s own body);
• loss of memory mainly for current events and actions (with complete retention of memory for past events);
• ignoring the left half of space (left field of vision);
• anagnosia;
• motor or total aphasia (in left-handers);
• cognitive impairment (pathology of concentration);
• emotional-volitional disorders and neuropsychopathological syndromes, which manifest themselves as depressive states, often giving way to carelessness and behavioral disorders with inadequate emotional reactions - disinhibition, foolishness, swagger, loss of sense of tact and measure with a tendency to flat jokes.

Features of ischemic stroke on the right side

This disease is characterized by polymorphism of symptoms with a longer period of restoration of lost functions. The right hemisphere is responsible for orientation in space, processing of familiar information, sensitivity and perception of the surrounding world. With thrombosis, embolism or significant spasm of the cerebral vessels of the right hemisphere of the brain, it causes complete or partial paralysis of the left side of the body. There is also a violation of short-term memory - the patient remembers past events well, but does not record his recent actions and life events at all.

In left-handed people, the speech center is located in the right hemisphere, so these patients often have motor or total aphasia, and they often lose the ability to communicate. An ischemic stroke of the right hemisphere of the brain causes patients to have no sense of their limbs as parts of their own body or to have more arms or legs.

Extensive right hemisphere stroke

With severe damage to the right hemisphere of the brain, at first, general cerebral symptoms prevail over focal ones, and their occurrence and progression are lightning fast and sudden (apoplectiform). This type of flow characterizes acute blockage of a large artery. Within a short time, focal symptoms also appear as strongly as possible and are combined with general cerebral neurological symptoms - loss of consciousness, vomiting, severe headache and dizziness, and impaired coordination of movements. Patients suddenly lose the ability to perceive shape and space, as well as the speed of movement and size of objects, the perception of their body disappears, swallowing, speech disorders and severe movement disorders (hemiparesis and paralysis of the left side of the body) disappear. Often patients who have suffered a right-sided ischemic stroke suffer from severe depression and mental passivity.

Major ischemic stroke right side brain causes severe damage that complicates the life and prognosis of the patient, disrupts the normal process of treatment and rehabilitation and more often causes disability and death in patients.

Features of right-sided lacunar strokes

Lacunar ischemic stroke localized in the right hemisphere of the brain develops against the background of progressive hypertension in combination with diabetes mellitus, vasculitis, toxic and infectious lesions of cerebral vessels, as well as at a young age in the presence of congenital defects of the vascular walls. It manifests itself in the initial stages in the form of transient ischemic attacks or small strokes, sometimes asymptomatically. General cerebral and meningeal symptoms for of this type stroke are not typical, and focal symptoms depend on the location of the lesion.

The characteristic signs of lacunar ischemic stroke of the brain are a favorable outcome with partial neurological deficit or complete restoration of lost functions, but with repeated lacunar strokes, the size of the ischemic focus increases, and a clinical picture of vascular encephalopathy is formed. There are several types of lacunar strokes - isolated motor stroke, ataxic hemiparesis, isolated sensory stroke and the main clinical syndromes: dysarthria, hyperkinetic, pseudobulbar, mutism, parkinsonism, dementia and others.

Manifestations of ischemic lacunar strokes

Right-sided isolated motor hemiparesis develops most often when the focus of necrosis is localized in the posterior third of the posterior thigh of the internal capsule, in the basal parts of the cerebral peduncles and in the parts of the pons. It is manifested by weakness in the muscles of the left arm and leg, as well as paresis of the facial muscles on the left. This type of lacunar stroke occurs in 50-55% of cases. In 35% of cases of right-sided lacunar strokes, hemiparesis develops in combination with hemianesthesia - left-sided paralysis of the facial muscles, paresis of the muscles of the arm and leg on the left with a violation of all types of sensitivity (pain, tactile, musculo-articular and temperature).

Atactic hemiparesis occurs in 10% of lacunar strokes and develops when the basal parts of the pons or the posterior femur of the internal capsule on the right are affected. It manifests itself as a combination of paresis of the limbs on the left with cerebellar ataxia. Less common are “dysarthria and clumsy hand syndrome,” which is a variant of ataxic hemiparesis, “isolated central paralysis of the facial muscles,” and “hemichori-hemiballisma” syndrome. The most severe manifestation of lacunar cerebral infarctions is the lacunar state - the formation of a large number of lacunar strokes in the cerebral hemispheres with severe pathology of the cerebral vessels and with a significant increase in blood pressure. This ischemic stroke is a manifestation of hypertensive angioencephalopathy.

Ischemic stroke in children and adolescents

Currently, in pediatric practice there is an increase in complex cerebrovascular pathology and an increase in the number of strokes in childhood and adolescence, and the consequences of strokes are extremely severe for both patients and their parents. There is a fairly high mortality rate in the development of ischemic strokes in children - from 5 to 16%. The reasons for the increase in cerebral circulatory disorders in children are: progressive severe cardiovascular diseases (birth defects heart, arrhythmias, rheumovasculitis, atrial myxoma), hereditary and acquired angiopathy of cerebral vessels (arteriosclerosis, viral angiitis), severe spastic processes (migrainous status), metabolic and endocrine diseases.

A separate type of ischemic cerebral stroke is perinatal stroke, which develops during prenatal period due to progressive placental insufficiency, severe intrauterine infections affecting the cerebral vessels of the fetus and congenital pathology of the heart and blood vessels with intravascular thrombus formation.

Features of the clinic of right-sided ischemic stroke in children

With the development of ischemic stroke of the right hemisphere in children, local (focal) neurological symptoms prevail over general cerebral symptoms. There is a high frequency of small strokes - lacunar with the development of a clinical picture of an isolated motor variant (left-sided hemiparesis with paralysis of the facial muscles on the left), ataxic ischemic stroke (with a predominance of symptoms of cerebellar damage and moderate paresis of the limbs on the left), as well as hyperkinetic and aphasic variants of lacunar cerebral infarctions.

The hyperkinetic type of stroke is manifested by a combination of hemiballismus and hemichorea with the subsequent development of dystonic disorders several months after the ischemic stroke (delayed dystonia). The aphasic variant develops with a lacunar stroke in the area of ​​the speech center and is manifested by speech disorders in left-handers (whose speech center is located in the right hemisphere of the brain). Also, additional symptoms of right-sided ischemic strokes in childhood are low-grade fever of unknown etiology or an increase in body temperature to high levels in case of extensive strokes. For the first time, quite often acute cerebrovascular accident occurs with symptoms of subclinical encephalomyopathy, but regression of neurological deficit after ischemic stroke in children occurs much faster, which is associated with good neuroplasticity of brain cells.

Pushkareva Daria Sergeevna

Neurologist, website editor