Risks and consequences of ischemic strokes localized in the right hemisphere. 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 hemispheres

Disturbances of higher mental functions with damage to the right hemisphere of the brain (a case study).

Abstract: Report from the experience of working with patients from the neurological department who have suffered a stroke. A practical case is presented in the identification and further restoration of some higher mental functions with focal damage in the right hemisphere of the brain.

According to the provisions of modern natural science, the human brain as a mental process always works as a whole. The right and left hemispheres are two parts of a single, albeit paired, organ.

With focal lesions of one of the hemispheres of the brain, leading to disruption of higher mental functions, the other hemisphere does not remain completely intact - the laws of compensation come into force.

Thus, with the right-sided localization of the lesion, the emotional-volitional sphere and visual-constructive activity suffered most pronouncedly; the left half of space was ignored; violations of direct memorization, acoustic and visual gnosis were more often detected.

There are conflicting opinions on the issue of functional restoration in patients with damage to the left or right hemisphere of the brain. Thus, L.G. Stolyarova and G.R. Tkacheva, V.N. Shmelkov, E. Anderson believe that in patients with damage to the right hemisphere, functions are restored worse due to their lack of awareness of their own defect and the resulting passivity in its correction.

However, T.D. Demidenko et al. do not see convincing data on the importance of the affected side for the outcome of rehabilitation therapy. S.Koppi et al., studying the rehabilitation prognosis in patients with different localizations of post-stroke focal lesions, note that lesions of the non-dominant hemisphere in elderly patients do not significantly reduce the effectiveness of the recovery process.

In the neurological department for patients with stroke, a neuropsychological examination is carried out on all patients who have suffered a stroke, regardless of the location of the lesion. If speech pathology or disorders of higher mental functions are detected, an individual rehabilitation training program is drawn up. This program provides classes using methods developed at the Center for Speech Pathology and Neurorehabilitation in Moscow (headed by V.M. Shklovsky) throughout the patient’s entire stay in the hospital.

Let me give you an example:

Patient S. Diagnosis: stroke of ischemic type in the territory of the right MCA. Early recovery period. Severe left-sided hemiparesis to the point of plegia in the arm.

Concomitant diagnosis: IHD. Progressive angina. Arterial hypertension grade 3, complicated form, risk 4. NC I. Generalized vascular atherosclerosis. CT scan of the brain: CT scan shows an ischemic stroke in the right MCA, atherosclerotic changes in cerebral vessels.

General characteristics of the patient in the experimental situation: he makes contact willingly, is sociable, adequate, oriented in place and time; criticality towards one's defect is reduced. Disturbances in the neurodynamic process: not identified. Condition of the muscles of the articulatory apparatus: tongue with slight deviation to the left, awkwardness and asymmetry of all articulatory postures, the nasolabial fold on the left is smoothed. Hypersalivation. Praxis.

Oral: awkwardness and asymmetry of all positions.

Dynamic Kinetic: Performs at a slow pace. Kinesthetic: preserved.

Constructive, spatial: gross disregard of the left field, disintegration of the ability to assess the integrity of the figure, due to the fragmentation of the image of the spatial situation.

Gnosis. Visual: preserved as a function, however, neglect of the left visual field is observed.

Spatial: ignoring the left visual field. Stereognosis: saved. Rhythmic patterns: Simple rhythmic patterns can be reproduced. Facial: saved. Memory: sufficient. Gestures, facial expressions: used in sufficient quantities.

Compiling a story on a given topic “North”: “It is not zonal or weather conditions that attract us. The concept of the North is associated not with climatic, not with zonal, but with industrial significance for Russia. The climate is sharply continental.

Climate – 108 degrees: from +50 to -58 degrees. The North is rich in resources: gas, oil and gas condensate. Berry crops are actively growing and both flora and fauna are rich.”

Compiling a story based on the painting “On the River”: “This painting apparently depicts people skating on a skating rink. One fell, and the other decided to ride on his stomach. The rest walk and look around the skating rink.”

(When looking at the picture, he ignores the left side of the field.)

The above example shows that when applying an individual rehabilitation training program, it is possible to obtain positive results from the activities carried out, regardless of the side of the hemisphere lesion, as well as in various periods after a cerebral accident, including in the long term of the disease, which undoubtedly increases the level of life of this patient population.

Despite the existing results assessing the quality and effectiveness of rehabilitation training for patients who have suffered a stroke in the right hemisphere, this topic requires further study.

Literature:

1. Bein E.S., Burlakova M.K., Vizel T.G. Restoring speech in patients with aphasia. M.: 1982
2.Wiesel T.G. Fundamentals of neuropsychology. M.: Astrel. 2005.- p. 58.
3. Vilensky B.S. Stroke: prevention, diagnosis and treatment. St. Petersburg: Foliot, 2002
4. Vygotsky L.S. Development of higher mental functions. M.: APN, 1960. – p. 500.
5. Efimova L.P., Kondratyeva A.M., Shabetnik O.I. A systematic approach to the rehabilitation of patients who have suffered a stroke in a specialized center. Tula: Bulletin of new medical technologies No. 3, 2007
6.Lukashevich I.P., Shipkova K.M., Shklovsky V.M. A structural approach to the presentation and analysis of neuropsychological information. 2003.
7. Luria A.R. Brain lesions and cerebral localization of higher mental functions. M.: MSU, 1982
8. Luria A.R. Functional organization of the brain. M.: MSU, 1976

Shabetnik O.I.,
Candidate of Pedagogical Sciences, speech therapist

Syndromes of damage to the right (subdominant) hemisphere have not yet been sufficiently studied. Method of cutting the corpus callosum (when cutting the corpus callosum and applying stimuli to the right hemisphere, naming objects is impossible, the ability to directly perceive objects and diffusely distinguish the meaning of words is preserved): Sperry confirmed that any HMF is carried out by the joint work of both hemispheres, each of which contributes one’s own contribution to the construction of mental processes.

The right hemisphere has nothing to do with speech activity, and its lesions, even quite extensive ones, do not affect speech processes. The subdominant hemisphere is less involved in providing complex intellectual functions and providing complex forms of motor acts. (right-handers with damage to the right hemisphere do not show pronounced impairments in active speech, writing (logical thinking, understanding of logical-grammatical constructions, formal logical operations, counting is also preserved), reading, even in cases where these lesions are located within the temporal, parieto-occipital, premotor zones, which in case of damage to the left hemisphere causes aphasia. The right hemisphere has less functional differentiation of cortical structures compared to the left: disturbances of the cutaneous and deep sensitivity of the right hand are caused by lesions of the postcentral parts of the left hemisphere, then the same disturbances of cutaneous and kinesthetic sensitivity in the left hand. may occur with significantly more diffuse lesions of the cortex of the subdominant hemisphere. Hulings Jackson (1874): the right hemisphere is directly related to perceptual processes and is an apparatus that provides more direct, visual forms of relations with the outside world. The right hemisphere is related to the analysis of the information that. the subject receives from his own body and which is not associated with verbal-logical codes. The role of the right hemisphere in immediate consciousness.

*superior parietal syndrome secondary areas - disturbances of the body diagram (left side)– somatoagnosia-impaired recognition of one’s own body parts and their tactile location to each other

*damage to the middle parietals - unilateral spatial agnosia– ignoring the left side of the body.

*damage to the posterior deep parts of the right p – left-sided fixed hemianopsia(violation of visual fields).

* Apraxia of dressing– disturbances in the sensations of your body, parts seem either very large or disproportionately small.

*Constructive agnosia and apraxia (TPO-inability to assemble into a single whole) are gnostic disorders. “Simultaneous agnosia” (Balint’s syndrome) – parieto-occipital regions. The patient correctly perceives only one image, since the volume of perception is narrowed, he cannot perceive the whole, only parts. + gaze ataxia - erratic, inconsistent eye movements.

*Impaired recognition of objects with damage to the posterior parts of the right hemisphere, loss of the sense of their familiarity. – facial agnosia– do not recognize relatives. + paragnosis - uncontrolled guessing when assessing an object.

The functions of the right hemisphere also include the general perception of one’s personality - anosognosia– do not notice them, are not critical of their own defects.

*profound changes in personality and consciousness - the perception of the situation as a whole becomes defective since there are no signals from the body, the phenomenon of disorientation in the surrounding world, time, confusion of immediate consciousness, verbosity and reasoning (since verbal-logical processes are preserved).

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.

Extensive ischemic stroke on the right side of the 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 are not typical for this type of stroke, 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 (congenital heart defects, arrhythmias, rheumovasculitis, atrial myxoma), hereditary and acquired angiopathy of cerebral vessels (arteriosclerosis, viral angiitis), severe spastic processes (status migraine), metabolic and endocrine diseases.

A separate type of ischemic cerebral stroke is perinatal stroke, which develops in the prenatal period due to progressive placental insufficiency, severe intrauterine infections affecting the fetal cerebral vessels 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 extremities 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

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 derealization. Colors in the patient's perception become dull; volumetric, three-dimensional objects - flat, two-dimensional. At the same time, the patient perceives himself as having 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 patients 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 entire surrounding world and his own “I” are perceived as changed. 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. The gross fallacy of reproducing the remoteness of already experienced events is interesting; 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, various options for an altered perception of one’s own “I” are described. 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 changes in the weight of one’s own body, which is explained by the activation in the cerebral cortex of those engrams that capture the acquired experience of subjective sensations during short-term changes in the weight of the body.

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, involuntaryity - 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, names of loved ones, even one’s age, place of work, 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 go unnoticed by the patient and 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 falling 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 consciousness disorder
A sudden onset and suddenly ending state of altered consciousness, which is characterized by the implementation of complex sequential psychomotor activity, ending with a 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 painful condition is anosognosia. Sometimes euphoria is combined to a pronounced degree with motor activity to the point of 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 unkind 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

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 suddenly 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 (most 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, they rarely seek medical help in the first days of the disease, when they 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.

Distortion of the face during a 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.

Nevertheless, right-hemisphere strokes in right-handed people have a more favorable prognosis for the restoration of motor and cognitive functions, in contrast to damage to the left hemisphere, which is 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 earlier treatment and rehabilitation are started, the greater the chance of returning the patient to a decent quality of life and preventing 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 also cannot be ruled out. But the chances of survival are enormous with 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. It is necessary to eliminate bad habits and 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.