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 old, 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 identifying 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 young children 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 children of senior 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 with damage to the right hemisphere occurred more often than with damage to the left hemisphere.

The same disturbances were 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 in 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 the symptoms of disorders in this area from the 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 the 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 is a 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 is recognized 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 an 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.

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 (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.

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.

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 chances of returning the patient 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.

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 cerebral infarction of the right hemisphere

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 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

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: disorders 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 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).

CHAPTER 15 HIGHER MENTAL FUNCTIONS AND SIGNS OF THEIR DISORDERS. SOME BRAIN DAMAGE SYNDROMES

CHAPTER 15 HIGHER MENTAL FUNCTIONS AND SIGNS OF THEIR DISORDERS. SOME BRAIN DAMAGE SYNDROMES

15.1. GENERAL PROVISIONS

Among the numerous functions performed by the brain, a very important place is occupied by the implementation of higher mental activity, which in humans has reached a particularly high level of development. Information entering the projection zones of the cerebral cortex, its specific processing and the formation of sensations lead to the formation of more complex categories - concepts - in the associative zones, based on their analysis and synthesis, as well as comparison with previous life experience extracted from the annals of memory. and ideas necessary to comprehend reality and form an adequate understanding of the situation and carry out thought processes.

Innate abilities, play and work skills, and accumulated life experience ensure the formation of higher mental functions (HMF), manifested, in particular, by a high level of cognitive abilities and the ability to perform complex motor acts, i.e. to development gnosis(from Greek gnosis - knowledge, recognition, objective perception) and praxis(from Greek praxis - action). The improvement of gnosis and praxis has led to the possibility of forming in humans a new stage in the development of mental activity - speech. Speech, language contributed to the development of abstract thinking - the highest achievement of nature, which contributed to the fact that a person who mastered speech was able to achieve an exceptional position among living beings inhabiting the Earth.

15.2. FUNCTIONAL ASYMMETRY OF THE HEMISPHERES OF THE BRAIN

The doctrine of interhemispheric asymmetry dates back to 1861, when the French physician P. Broca (Broca P., 1824-1880) established the presence of the so-called motor speech center in the left hemisphere of the brain. Research in subsequent years made it possible to create an idea of ​​the difference in the participation of the left and right hemispheres in mental activity. The hemisphere, on which the function of speech primarily depends, began to be called dominant. For most people, it turned out to be the left hemisphere.

The understanding of the functional differences in the role of the right and left hemispheres of the brain in the formation of the human psyche was facilitated by the examination of patients who underwent operations: 1) prefrontal leucotomy - cutting of the paths connecting the frontal parts of the hemispheres with the subcortical formations, developed in 1935 by E. Moniz (Moniz E. , 1874-1955) for the treatment of patients with affective psychoses and schizophrenia; 2) dissection of the corpus callosum - splitting of the brain for the purpose of treating epilepsy. In 1949, the Portuguese neurosurgeon E. Moniz was awarded the Nobel Prize for the development of these operations.

In the 60s of the XX century. Brain research after commissurotomy was conducted by R. Sperry, professor of psychology at the University of California (USA). He found that after dissection of the corpus callosum, processes in each hemisphere proceed independently, as if two people were acting, each with their own life experience. Each hemisphere has its own functions: in the left - speech, writing, counting, in the right - the perception of spatial relationships and recognition that is not differentiated by words. For these studies, R. Sperry received the Nobel Prize in 1981.

A great contribution to the development of the problem of interhemispheric asymmetry was made by a group of neuropsychologists led by A.R. Luria (1902-1977), who worked at the Research Institute of Neurosurgery named after. N.N. Burdenko in the 50-70s.

The functional asymmetry of the left and right hemispheres can be considered as an evolutionary acquisition, reflecting the exceptionally high level of functional differentiation of his brain achieved by man. According to one hypothesis, with the appearance of the rudiments of abstract thinking and speech in the distant ancestors of modern man, these functions were taken over by the left hemisphere. In this regard, the right hand, associated with the left hemisphere, gradually became more active and at the same time stronger and more dexterous. Abstract thinking and speech, being interdependent, gradually improved and became increasingly important for humans.

In the right hemisphere, the functions of concrete thinking, perception and differentiation of non-speech sounds and music were further developed. There is an opinion that the right hemisphere has advantages in ensuring self-awareness, in orientation in external space, in recognizing people by individual facial features, voice, and in constructing objective actions.

In the formation of functional asymmetry of the cortical fields of the cerebrum during the process of ontogenesis and subsequent development of the child, heredity plays an important role. It is recognized that in some people, usually left-handed people, a peculiar rotation of mental functions is possible and then the right hemisphere may become dominant. However, in left-handers, in most cases, the asymmetry of the hemispheres is not as pronounced as in right-handers, and there is often a convergence of the functional capabilities of the right and left hands, and in this case they speak of ambidexterity.

In practice, sometimes there is a need to find out whether a particular patient is right-handed or left-handed, and thus roughly determine which of his hemispheres should be recognized as dominant. There are several methods for such differentiation. You can find out which hand the patient has stronger, which hand has stronger and more dexterous fingers. Hand strength can be tested with a hand dynamometer. You should check which hand the patient prefers to cut bread, light a match, etc. Contra-

The hand lateral to the dominant hemisphere is usually on top if the patient applauds and folds his arms on his chest (“Napoleonic style”). The thumb of this hand usually ends up on top if you ask the patient to bring their hands together so that the fingers of one of them are between the fingers of the other. On the side opposite the dominant hemisphere, there is usually the so-called pushing leg.

In 1981 N.N. Bragin and T.A. Dobrokhotova proposed a classification of functional asymmetries. The disparity in motor activity of the right and left halves of the body is considered in it as motor asymmetry. The disparity in the perception of objects located to the right and left of the sagittal plane of the body is designated as sensory asymmetry. Finally, the specialization of the right and left hemispheres of the brain in the implementation of various forms of mental activity is recognized asymmetry of mental functions.

In the process of development of the VPF one of the hemispheres, called the dominant (usually the left), specializes in providing abstract thinking and speech - functions peculiar only to humans. The left hemisphere, in addition, turned out to be leading in the formation of the most complex abstract mental processes. The development of the right hemisphere creates the opportunity to improve concrete thinking, capture and adequately evaluate the features of speech intonations, perceive and differentiate non-speech sounds, in particular the sounds of music. The right hemisphere provides general, visual and spatial perception (Table 15.1).

Table 15.1.Interhemispheric asymmetry

Some modern psychologists and physiologists (Batuev A.B., 1991, etc.) believe that a person with a predominance of left-hemisphere functions gravitates toward theory, has a larger vocabulary and actively uses it, he is characterized by vital activity, determination, and the ability to predict events. A “right-hemisphere” person gravitates toward specific types of activities; he is slow and taciturn, but endowed with the ability to sensitively

to think and experience and is prone to contemplation and reminiscence. Normally, most people are characterized by a duality of these extreme manifestations of behavior and psyche.

There is an opinion (Kostandov E.A., 1983) that in a healthy person there is complementary cooperation of both hemispheres and the advantage of the function of one of them manifests itself only at a certain stage of one or another type of neuropsychic activity. It is noted that, apparently, the right hemisphere processes incoming information faster than the left. Visual-spatial analysis of stimuli is first carried out in the right hemisphere and then transferred to the left, where the final higher, semantic analysis and awareness of the nature of these stimuli occurs.

Currently, there are grounds for summarizing the accumulated information about interhemispheric asymmetry and determining the significance of this asymmetry for human mental activity. T.A. Dobrokhotova, N.N. Bragina et al. in 1998, based on literary and own materials on this problem, they came to the conclusion that brain asymmetry can be presented as a manifestation of its functional maturity. It increases in childhood, ensuring the normal mental development of the child, reaches a maximum in adulthood, determining the possible effectiveness of mental activity for a given person, and is leveled out at a later age, which is manifested by a gradual decrease in the productivity of mental processes.

15.3. DISORDERS OF HIGHER MENTAL FUNCTIONS

Asymmetry of the functions of the cerebral hemispheres leads to very significant features of the clinical picture in patients with damage to the left or right hemispheres of the cerebral hemisphere (Table 15.2). Knowledge of these features can help clarify the topical diagnosis.

Table 15.2.Features of mental function disorders with damage to the left and right hemispheres of the cerebrum

End of table. 15.2

With disturbances in the development of the cerebrum or its damage, disorders of higher mental functions arise, in particular gnosis, praxis and speech, while their implementation is largely determined by the characteristics of the activity of certain associative zones of the cerebral cortex. Damage to these cortical zones leads to the development of variants of disturbance of gnosis, praxis, speech, and memory. These disorders are known as agnosia, apraxia, aphasia, and amnesia.

15.3.1. Agnosia

Agnosia is a disorder of gnosis - disturbances in the understanding and recognition of objects and phenomena that arise in connection with a disorder of the functions of higher gnostic (cognitive) mechanisms that ensure the integration of elementary sensations, perceptions and the formation of holistic images in the mind. The term “agnosia” was introduced in 1881 by the German physiologist G. Munk (Munk H., 1839-1912).

Agnosia is multivariate, most of them are sensitive.

Sensitive agnosia - the inability to recognize and understand objects and phenomena on the basis of individual sensations (agnosia auditory, gustatory, tactile, visual, etc.) or their synthesis. Such forms of agnosia are usually associated with damage to the associative territories of the cortex located in the vicinity of the corresponding projection zones. They can be combined with a disorder of orientation in place and time.

The consequence of sensitive agnosia is disorders of complex types of sensitivity, in particular two-dimensional and three-dimensional spatial senses. These disorders occur when the cortex of the lower parts of the parietal lobe is damaged and manifests itself in the contralateral limbs.

Spatial agnosia - disorientation in space or ignoring part of the surrounding space, usually its left half with a pathological focus in the right parietal lobe. The patient reads the text only on the right half of the page, copies only the right side of the image, etc.

Auditory or acoustic agnosia - a variant of sensitive agnosia, in which a disorder of recognition of audible sounds manifests itself. In cases of damage to associative fields in the localization zone of the cortical end of the auditory analyzer in the dominant hemisphere, usually on the left, phonematic hearing is impaired, and, in connection with this, the understanding of audible speech. Damage to similar cortical fields on the right leads to impairment of the ability to recognize non-speech object sounds (the rustling of leaves, the murmur of a stream, etc.), recognize and reproduce musical melodies (amusia), while the perception of the melody of audible (including one’s own) speech, its timbre, is also disrupted,

intonation, which may ultimately manifest itself impaired recognition of a familiar person “by voice” and lead to an inadequate assessment of audible statements, since the meaning of speech is determined not only by the composition of the words, but also by the intonation with which they are pronounced.

Visual agnosia - disorder of the synthesis of individual visual sensations and in connection with this impossibility or difficulty in recognizing objects and their images with intact vision. It is especially difficult to recognize an object by its conventional (contour, line, fragmentary, etc.) image (Fig. 15.1); in particular, it is difficult to recognize layered contour images (Poppelreiter’s drawings). Visual agnosia occurs when the cortex of the occipital-parietal region is damaged (fields 18, 19, 39). With visual agnosia, the patient is unable to draw a given object, since his holistic perception of its image is impaired (Fig. 15.2). Variants of visual agnosia are visuospatial agnosia, face agnosia, apperceptive and associative agnosia.

Visuospatial agnosia, or spatial apractagnosia - visual agnosia, in which the patient experiences difficulties in forming an idea of ​​the spatial relationships between objects. This leads to a violation of the ability to differentiate left and right, to errors in determining time using a watch dial, when working with a contour map, to a violation of the ability to navigate the area, draw up a room plan, etc., while patients usually have signs of spatial apraxia. Occurs when tertiary associations are damaged

Rice. 15.1.An example of an image of objects with intersecting contours (Fig. Papelmeyer), used to identify visual agnosia.

Rice. 15.2.Identification of spatial agnosia.

a - drawings offered to the patient; b - attempts to copy these drawings by patients with damage to the right parietal lobe, ignoring the left half of the space.

zones of the parieto-occipital cortex, usually the right hemisphere of the brain. Described by the French neurologist P. Marie (1853-1940).

Agnosia for faces (prosopagnosia) - visual agnosia, manifested failure to recognize faces or portraits images (drawing, photograph, etc.) acquaintances relatives or well-known people (Pushkin A.S., Tolstoy L.N., Gagarin Yu.A., etc.), and sometimes the patient cannot recognize himself in a photograph or in a mirror. At the same time, he often recognizes familiar people by their clothes and voice. This is a sign of damage to the cortex of the secondary association zone in the right occipital-parietal region. Described in 1937 by H. Hoff and O. Petzel.

Lissauer's apperceptive agnosia - a variant of visual agnosia. The patient can perceive simple figures, such as a ball, but does not recognize complex images due to limitations in visual perception; he recognizes only their individual features (size, shape, color, etc.). However, the synthesis of these elements, and therefore recognition of the object as a whole, is inaccessible to the patient. Entitled "apperceptive mental blindness" this form of agnosia was described in 1898 by H. Lissauer.

At associative visual agnosia sick with the help of vision, he perceives objects or their images, but is not able to correlate them with his previous experience, recognize and determine their purpose. In this case, patients often confuse objects that have some similarities or their images, for example, glasses and a bicycle. It is very difficult to recognize silhouette, stylized or contour drawings, especially in cases where the latter overlap.

on a friend (drawings by Poppelreiter). All these defects in visual perception are more clearly manifested when the examination is carried out under time pressure (0.25-0.5 s), recorded using a tachistoscope. The disease is usually manifests itself when the parieto-occipital region of the right hemisphere of the brain is damaged. This form of visual agnosia was described in 1898 by N. Lissauer as associative mental blindness. A.R. Luria (1973) believed that the basis of the syndrome is not optical agnosia, but rather paragnosia.

Balint syndrome- a form of visual agnosia, manifested by “mental gaze paralysis”, in which the patient cannot simultaneously perceive several object images at once. Often combined with gaze apraxia. Sick unable to look in a given direction or turn his gaze towards an object that appears in the peripheral part of the visual field. More often occurs with bilateral or right-sided ischemic foci in the parieto-occipital region. Lack of “visual attention” is manifested by the inability to simultaneously see two or more small objects located at some distance from each other (simultaneous agnosia). If an object accidentally appears in the field of view, the patient sees it, but does not perceive everything else, while it is difficult for him to understand the architectonics of what is visible, for example, seeing a cross, the patient cannot point to its center (crosshair), draw a clock dial, cannot perceive the situation as a whole, understand the plot picture, etc. Balint's syndrome is usually combined with optical ataxia - the inability to point to or pick up an object under visual control due to disorientation in space. Sometimes manifestations of apraxia are also noted. The syndrome was described in 1909 by the Hungarian psychoneurologist R. Balint (1874-1929). It usually occurs with bilateral lesions of predominantly the inferior parietal-occipital region cerebral hemispheres.

Somatoagnosia- autotopagnosia, a violation of the body diagram. Its variants are anosognosia, finger agnosia. Somatoagnosia - impaired perception of one's own body image, which develops from an early age on the basis of tactile, kinesthetic, visual and other sensations. Violation of the body diagram leads to an inadequate perception of one’s own body, individual parts of which on the side opposite the pathological focus may appear changed in size and shape (metamorphopsia and its varieties - macro- and micromorphopsia). There may be a sensation of an extra (third) arm or leg (pseudopolymelia) or absence (“loss”) of any part or all half of the body (anosognosia, agnostic Babinski syndrome, Redlich syndrome), usually on the left, and can be considered a variant of unilateral spatial agnosia. Somatoagnosia is observed with damage to the parietal lobe cortex (fields 30 and 40), usually in the right hemisphere. When the lesion is localized in a similar zone of the left hemisphere, somatoagnosia occurs 7 times less frequently. This pathology may be a sign of organic damage to the thalamoparietal system (tumor, stroke, contusion lesion, etc.), and is usually combined with hemiparesis, a severe general condition. Somatoagnosia can also be one of the manifestations of derealization and depersonalization in epilepsy, schizophrenia, etc.

A variant of somatoagnosia can be considered finger agnosia- sensitive agnosia, in which the patient’s inability to recognize, name and show the fingers of his hand is manifested. It is usually noted with damage to the parieto-occipital region of the left hemisphere.

Apraxia is a disorder of voluntary purposeful actions and motor skills with the preservation of their elementary movements.

Normally, acquired motor skills depend on previously formed movement patterns, which are remembered and can be reproduced under appropriate circumstances. Any conscious activity consists of stages. The first of these is the impulse to action that arises in a stimulating situation. For most people (right-handed people), the urge to action and the inclusion of a previously acquired scheme of a motor act and its implementation associated with the state of the left parietotemporal region, having connections with the left premotor zone, which controls the movements of the right hand, and from there, through the corpus callosum, with the motor zone of the right hemisphere, which controls the movements of the left limbs. In this regard, damage to the middle parts of the corpus callosum leads to apraxia in the left limbs, while damage to the left parietotemporal region can lead to total apraxia (Fig. 15.3).

Rice. 15.3.Formation of apraxia in the left hand with damage to the corpus callosum.

1 - cortex of the left parietal lobe; 2 - pathological focus; 3 - precentral gyrus, hand projection area; 4 - corticospinal tracts; 5 - peripheral motor neuron in the cervical thickening of the spinal cord.

Apraxia can be detected when the patient performs certain motor acts (the patient must show how he uses a comb, toothbrush, etc., repeat the doctor’s gestures, carry out certain simple actions according to a verbal task). In 1900, at the suggestion of H. Liepmann (1863-1925), ideational, motor and constructive apraxia were distinguished. Later, its other forms were described. Particularly significant in the study of apraxia and other disorders of higher mental functions are the works of the Russian neuropsychologist A.R. Luria and his schools.

Ideatorial apraxia, or apraxia of design, characterized inability to draw up a plan of sequential actions, necessary to perform a previously unlearned complex motor act, while the patient is unable to correct his actions. However, if such an action was learned earlier, then it can be performed automatically due to already established reflex mechanisms. The pathology was described by the German psychiatrist H. Lipmann as a consequence of damage to the premotor cortex of the frontal lobe of the dominant hemisphere big brain.

Ideomotor apraxia - apraxia, in which execution of tasks is disrupted (clench a fist, light a match, etc.), whereas these actions are performed correctly by the patient when performing automated motor acts. It is especially difficult for the patient to imitate actions with missing objects: to show how sugar is stirred in a glass, how to use a spoon, hammer, comb, etc. The disease is a consequence of damage to the premotor zone cortex of the dominant cerebral hemisphere. When the pathological focus is localized on the left in right-handed people, ideomotor apraxia is bilateral. If the focus is localized in the right parietal region or in the middle third of the corpus callosum, then ideomotor apraxia appears only on the left.

Motor,or kinetic, apraxia characterized violation of the implementation of a motor act while maintaining the ability to plan it,

At the same time, actions based on imitation, as well as those based on instructions, are impossible to carry out. However, the movements performed turn out to be unclear, awkward, often redundant, and poorly coordinated. The patient cannot perform symbolic movements (wag a finger, salute, etc.). Sometimes this pathology is combined with motor aphasia and agraphia and manifests itself more often in the right hand with damage to the lower parts of the left frontoparietal region. The disease was described in 1805 by N. Liepmann (1863-1925).

A variant of motor apraxia is frontal apraxia- a consequence of a violation of the ability to program and perform a sequential series of movements. Manifested by a disorder of their tempo and smoothness, violation of the “kinetic melody”, necessary for a given purposeful action. There is a tendency towards motor perseveration (repetition of elements of a motor act or the entire movement), general muscle tension. In this case, the patient cannot tap out a series of strong and weak rhythmic beats in a certain sequence; when writing, repetition of individual letters or their elements is noted. Frontal apraxia - manifestation of damage to the premotor region of the frontal lobe.

Constructive apraxia - apraxia, in which it is difficult to place objects in two-dimensional and three-dimensional spaces, in this case, the patient cannot put together a whole from parts, for example, a given figure from matches or from a mosaic, cubes, put together a picture from its fragments, etc. Similar actions

The patient cannot perform the task both according to instructions and as a result of imitation. Usually occurs when the ability to normal orientation in space is lost in cases lesions of the cortex of the angular gyrus, the region of the intraparietal sulcus and adjacent parts of the occipital lobe.

Apraxia of dressing (Brain's syndrome) - dressing disorder due to the fact that the patient confuses the sides of clothing, it is usually especially difficult to put on the left sleeve and left shoe. Apraxia of dressing - variant of constructive apraxia, wherein lesion most often localized in the right parieto-occipital region. The syndrome was described by the English neurophysiologist W. Brain (born in 1885).

Kinesthetic or afferent apraxia - manifestation lesions of the cortical areas of the parietal region adjacent to the postcentral gyrus, on the area of ​​the opposite side of the body, projected onto the nearest fragment of the posterior central gyrus, is accompanied by a disorder of fine differentiated movements. It is a consequence of a lack of information about the position of body parts in space (impaired reverse afferentation), which leads to movement disorders. During the period of active movement, the patient cannot control the progress of its implementation, so movements become uncertain, unclear, movements that require significant complexity are especially difficult. Kinesthetic apraxia includes elements of ideomotor and kinetic apraxia. Kinesthetic (afferent) apraxia was described in 1947 by the domestic neuropsychologist A.R. Luria.

A variant of kinesthetic apraxia is oral apraxia, manifested by dysfunction of the muscles involved in speech and swallowing, leading to speech impairment of the afferent motor aphasia type.

Spatial apraxia - disorder of spatially oriented movements and actions. It appears, for example, when simulating the movements of the hands of a doctor located opposite the patient during tests by H. Head (1861-1940).

Apraxia of gaze- absence of voluntary movements of the eyeballs to the sides while involuntary movements of the gaze are preserved. For example, the patient cannot turn his gaze according to the instructions, but follows the moving object with his eyes.

Apraxia of walkingcharacterized walking disorder in the absence of motor, proprioceptive, vestibular disorders, observed when the cortex of the frontal lobes (premotor area) is damaged.

15.3.3. Aphasia

Aphasia (from Greek a - denial + phasis - speech) - a general designation for speech disorders that occur in people with intact articulatory apparatus and sufficient hearing, in which the ability to actively use speech to express thoughts and feelings and/or understand audible speech is partially or completely lost. With aphasia, the grammatical and lexical structure of speech is disrupted. The term “aphasia” was introduced in 1864 by the French physician A. Trousseau (Trousseau A., 1801-1867).

Purposeful study of speech function began in the second half of the 19th century. In 1861, P. Broca (Broca P.) described a violation of the ability to speak that occurs when the posterior parts of the third frontal gyrus (center

Broca). In 1873, K. Wernicke K. discovered that when the functions of the posterior third of the superior temporal gyrus (Wernicke's center) are impaired, speech understanding is impaired. The first of the mentioned forms of speech disorder is called motor (efferent, expressive) aphasia, the second - sensory (afferent, expressive). At the same time, it was noted that aphasia usually occurs as a result of a pathological process in the left hemisphere of the brain, which is leading (dominant) in most right-handed people. In the same hemisphere, later in 1914, areas of the cortex were described, the defeat of which leads to a selective impairment of reading - alexia (angular gyrus of the parietal lobe) (Dejerine J.J., 1914) and writing - agraphia (posterior parts of the middle frontal gyrus) (Exner S ., 1881).

In 1874, the German doctor K. Wernicke (Wernicke K., 1840-1905) and in 1885 the Swiss doctor L. Lichtheim (Lichtheim L., 1845-1928) proposed a classification of aphasia, which was recognized as classical. The authors sought to reflect in it the possible features of aphasia that occur in cases of lesions in various zones of the dominant hemisphere. They identified 7 forms of aphasia, 2 of which are main: cortical motor and sensory. The remaining 5 forms of aphasia were considered as a consequence of disruption of connections between Broca's and Wernicke's centers (conduction aphasia), between these centers and the hypothetical center of concepts (transcortical motor and sensory aphasia) and explained by damage to projection fibers going to the main speech centers: subcortical motor and sensory aphasia .

In 1908, K. Wilson (Wilson K.) and in 1913, G. Lipmann (Liepmann H., 1863-1925) considered the main forms of aphasia as peculiar variants of apraxia and agnosia, which met with serious objections. H. Jackson (Jackson J.H., 1834-1911), who paid much attention to higher mental functions and methods of studying them in normal conditions and in diseases of the brain, came to the conviction that will, memory, thinking, speech are elements of consciousness and cannot be localized on some part of the brain. He was the first among neurologists to proclaim a dynamic approach to the manifestations of his lesions. A similar point of view was shared by G. H., who proposed considering speech disorders based primarily on the achievements of linguistics. Like H. Jackson, he denied the possibility of connecting certain features of speech function with certain areas of the brain. They identified 4 forms of aphasia: verbal, nominative, syntactic and semantic.

In the 60-70s of the XX century. A.R. Luria developed a classification of aphasia, which is based on the results of a synthesis of morphological, syndromological and linguistic concepts. The classification was formed in the process of constant communication with neurosurgical patients and, thus, underwent clinical testing. A.R. Luria identified 3 forms of expressive speech impairment (motor aphasia): afferent (kinesthetic), efferent (kinetic) and dynamic, as well as 2 forms of impressive speech impairment: sensory and semantic aphasia; in addition, he recognized the existence of amnestic aphasia.

Afferent motor aphasia arises in case of damage to the postcentral parts of the dominant hemisphere (lower part of cortical fields 1, 2, 5, 7, partially 40), receiving information from proprioceptors of the speech motor apparatus and providing the kinesthetic basis of articulation. When this part of the brain is damaged, coordination loss occurs

the work of the muscles involved in the formation of speech, and Errors appear when pronouncing individual speech sounds, primarily homoorganic ones, i.e. with similar phonetic features (for example, anterior lingual “t”, “d”, “n”; fricative “sh”, “sch”, “z”, “x”; labial “p”, “b”, “m”).

In this regard, expressive speech turns out to be slurred, numerous sound substitutions occur in it, which makes it incomprehensible to others, while the patient himself is not able to control it due to a kind of sensitive ataxia in the structures that ensure the formation of speech. Afferent motor aphasia is usually combined with oral (buccal-lingual) apraxia (inability to reproduce on instructions movements of the tongue and lips that require significant precision - placing the tongue between the upper lip and teeth, etc.) and is characterized by a violation of all types of speech production ( speech spontaneous, automated, repeated, naming). Detailed information about afferent motor aphasia is presented in the monograph by E.N. Vinarskaya (1971).

Efferent motor aphasia - consequence damage to the lower parts of the premotor zone in the posterior part of the inferior frontal gyrus (Broca's area: cortical areas 44 and 45). Articulation of individual sounds is possible, but switching from one speech unit to another is difficult. The patient’s speech is slow, he is laconic, there is poor articulation, which requires significant effort from him, speech is replete with numerous literal and verbal perseverations (repetitions), which is manifested, for example, by a disorder in the ability to alternate individual syllables (ma-pa-ma-pa). Due to the omission of auxiliary words and case endings, the patient’s speech sometimes becomes “telegraphic.” With pronounced manifestations of this form of aphasia, it is possible formation of “speech emboli” in patients - repetition of certain words (often swear words), which the patient pronounces “out of place,” while conveying his attitude to the situation through intonation. Sometimes the patient is able to repeat individual words after the examiner, but he cannot repeat a phrase, especially an unusual one, devoid of meaning. The nominative function of speech (naming objects), active reading and writing are impaired. At the same time, understanding of oral and written speech is relatively intact. It is possible to preserve fragmentary automated speech and singing (the patient can hum a melody).

Patients are usually aware of the presence of a speech disorder and sometimes have a hard time experiencing the presence of this defect, showing a tendency to depression. With efferent motor aphasia of Broca on the side of the subdominant hemisphere usually there is hemiparesis, At the same time, the severity of paresis is more significant in the hand and face (according to brachiofacial type).

Dynamic motor aphasia arises with damage to the prefrontal area anterior to Broca's areas (areas 9, 10, 11, 46), it is characterized by a decrease in speech activity and initiative. Reproductive (repetition of words and phrases after examination) and automated speech suffer significantly less. The patient is able to articulate all sounds and pronounce words, but his motivation to speak is reduced. This is especially clear in spontaneous narrative speech. Patients seem to be reluctant to enter into verbal contact; their speech is simplified, reduced, and exhausted due to the difficulty of maintaining a sufficient level of mental activity in the process of verbal communication. Activation of speech in such cases is possible through a stimulating effect on the patient, in particular by talking on a topic

having a high degree of personal significance for the patient. This form of aphasia was described by A.R. Luria. It can be explained as a consequence of a decrease in the influence on cortical structures from the activating systems of the reticular formation of the oral parts of the brain stem.

Sensory aphasia, or acoustic-gnostic aphasia, arises with damage to Wernicke's area, located next to the cortical end of the auditory analyzer in the posterior part of the superior temporal gyrus (field 22). The basis of sensory aphasia is disorder of speech recognition in the general sound stream due to impaired phonemic hearing (phonemes are units of language with the help of which its components are differentiated and identified; in Russian speech, these include, in particular, voiced and voiceless, stressed and unstressed), in this case, a violation of sound-letter analysis and alienation of the meaning of words occurs.

With sensory aphasia, the ability to repeat words is also lost. The patient cannot correctly name familiar objects. Along with the impairment of the patient’s oral speech, the ability to understand written speech and read is also impaired. Due to a disorder of phonemic hearing, a patient with sensory aphasia makes mistakes when writing, especially when writing from dictation, primarily characterized by substitutions of letters reflecting stressed and unstressed, hard and soft sounds. As a result, the patient’s own written speech, like oral speech, seems meaningless, but the handwriting may remain unchanged.

In typical, isolated sensory aphasia, manifestations of hemiparesis on the side opposite the dominant hemisphere may be absent or mild. However Possible upper quadrant hemianopsia due to the involvement of the lower part of the optic radiation (Graciole bundle) in the pathological process passing through the temporal lobe of the brain.

Semantic aphasia arises with damage to the inferior parietal lobule (fields 39 and 40). It is manifested by difficulties in understanding phrases that are somewhat complex in construction, comparisons, reflexive and attributive logical-grammatical phrases expressing spatial relationships. Sick does not understand the semantic meaning of prepositions, adverbs, endings: under, above, before, behind, above, below, lighter, darker, etc. It is difficult for him to understand the difference between the phrases: “The sun is illuminated by the Earth” and “The Earth is illuminated by the Sun”, “Father’s brother” and “Brother’s father”, to give the correct answer to the question: “If

Vanya is following Petya, then who is ahead?”, according to the instructions, draw a triangle in a circle, a cross over a square, etc.

Amnestic (anomic) aphasia observed with damage to the posterior parts of the parietal and temporal lobes of the left hemisphere, mainly the angular gyrus (fields 37 and 40), and is manifested by the inability to name objects; in this case, the patient can correctly speak about their purpose (for example, when the examiner asks to name the pencil being shown, the patient states: “Well, this is what they write with,” and usually strives to show how it is done). The hint helps him remember the right word for the name of the object, and he can repeat this word. In the speech of a patient with amnestic aphasia there are few nouns and many verbs, while active speech is fluent, and understanding of both oral and written speech is preserved. Concomitant hemiparesis on the side of the subdominant hemisphere is uncommon.

Total aphasia - combination of motor and sensory aphasia: the patient does not understand the speech addressed to him and at the same time turns out to be incapable of actively pronouncing words and phrases. It develops more often with extensive cerebral infarctions in the basin of the left middle cerebral artery and is usually combined with severe hemiparesis on the side of the subdominant hemisphere.

One of the leading modern aphasiologists M. Critchley (Critchley M., 1974) proposed taking into account manifestations that are often encountered in the clinic minimal dysphasia, or preaphasia, in which a speech defect manifests itself so easily that during a normal conversation it can go unnoticed by both the speaker and his interlocutor. Preaphasia is possible both with increasing brain pathology (atherosclerotic encephalopathy, brain tumor, etc.), and in the process of restoration of impaired functions after a stroke, brain injury, etc. (residual dysphasia). Its identification requires particularly careful research. She can manifest itself in the form of speech inertia, spontaneity, impulsiveness, decreased ability to quickly and easily select the right words, and the use of predominantly words that appear in the patient’s dictionary with great frequency. Rarer words are recalled with difficulty and with delay, and the patient often replaces them with more frequently occurring, although less appropriate words in the given context. In the speech of patients, “clichéd” words and phrases, speech “cliches,” and habitual speech patterns become abundant. Not finding the exact words and phrases in a timely manner, the patient tends to substitute words (“well, this thing, what’s its name”) and thus compensate for the lack of quality of one’s speech with an excessive amount of speech production, which results in excessive verbosity. If the patient performs individual tasks correctly, then performing a serial task (for example, touching the bridge of the nose with the index finger of the right hand, holding oneself by the right ear with the left hand and closing the left eye) is difficult. Verbally presented material to patients is poorly interpreted and inaccurately repeated; difficulties arise in explaining the meaning of such generally accepted expressions and proverbs as “golden hands”, “take the bull by the horns”, “there are devils in still waters”, etc. There may be difficulties when listing objects belonging to a certain class (animals, flowers, etc.). Speech disorders are often identified when the patient compiles an oral or written story based on a picture or on a given topic. In addition to other difficulties, in the process of communicating with a patient, uncertainty in the perception of a verbal task and the resulting slowness of reactions to it may be noted.

Methods for identifying aphasia. In order to identify aphasia, expressive speech is tested: spontaneous speech (the patient’s participation in dialogue, the ability to give specific answers to questions), automated speech (listing seasons, days of the week, months, etc.), naming objects and their images, repeated speech - repetition after the examiner of vowels, fricatives, plosives, anterior lingual, labial consonants and sound combinations that have a different phonetic basis: “b-p”, “t-d”, “g-k”, “pa-ba”, “da-ta”, “to-do”), repetition of simple words (“table”, “forest”, “thunder”), more difficult words (“constitution”, “shipwreck”), phrases of varying complexity, tongue twisters ( “Clara stole the corals”, “thirty-third artillery brigade”, etc.). When checking impressive speech, you should make sure that the patient understands the meaning of individual words and phrases (he should show the objects called by the examiner, body parts, images in pictures, explain the difference between words that sound similar, for example, “barrel-kidney-daughter”). The patient’s understanding of simple and more complex tasks is also checked: touch the right ear with the finger of the left hand, knock on the table three times. To test phonemic hearing, the patient’s ability to distinguish between close phonemes (“sa-za”, “da-ta”) is revealed, and the understanding of the meaning of phrases that have a complex logical-grammatical structure, such as those given in the paragraph on semantic aphasia, is checked.

Aphasia can be combined with other neuropsychological and focal neurological symptoms: alexia, agraphia, acalculia, apraxia, agnosia, dysarthria, speech akinesis, aphonia, signs of pyramidal insufficiency. Therefore, to determine a topical and nosological diagnosis, there is usually a need for a complete neurological and neuropsychological examination of the patient, and, if necessary, additional studies (neurophysiological, radiological, etc.).

When diagnosing aphasia, one should take into account the level of intellectual development of the patient, the state of his hearing, general condition and level of consciousness during the examination period. It may be necessary to differentiate the manifestations of aphasia from dysarthria, aphonia, mutism, and alalia. It should be taken into account that the nature of speech can change with the development of dementia and various forms of mental pathology and in these cases has features that distinguish it from aphasia.

Aphasia is usually combined with reading (alexia) and writing (agraphia) impairments, while in aphonia and dysarthria they are not typical. In such cases, the patient can usually write and read, while in the first case the sonority of the voice is impaired, in the second there is unclear pronunciation, but the patient has no impairment in understanding the speech addressed to him and reading “to himself” corresponds to the level of intellectual development and general condition of the patient.

It should also be noted that dysarthria, manifested only by dysfunction of the speech-motor apparatus, is possible with damage to various levels of the brain. With damage to the precentral gyrus cortex of the dominant hemisphere, it is possible cortical dysarthria, characterized by phonetic-articulation disorders.

15.3.4. Alexia

Alexia- acquired a reading disorder, which in most cases can be considered a consequence of aphasia. With relatively mild manifestations of aphasia, reading is possible, but there are omissions and

rearrangements of letters (literal paralexia), omissions and substitutions of words (verbal paralexia), misunderstanding of what is read. In severe cases of aphasia, reading both aloud and silently becomes impossible.

Alexia in combination with agraphia in the absence of aphasic disorders may be a consequence of one of the variants of visual agnosia, known as letter agnosia. It occurs when the cortex of the posterior part of the angular gyrus of the parietal lobe (field 39) of the dominant hemisphere is damaged, in this case, the patient does not recognize letters when reading and writing or makes mistakes when differentiating letters with similar designs (I-N-P, 3-E, Sh-Sh-Ts, etc.). There may also be a disorder in the adequate perception of numbers and musical notes. This form of pathology is known as optical, or parietal, aphasia. It was described in 1919 by the Austrian psychiatrist O. Potzl (Potzl O., 1877-1962).

Alexia without agraphia is extremely rare, in which the pathological focus is located in the cortex of the medial part of the occipital lobe and in the splenium of the corpus callosum. Alexia in such cases is accompanied by right-sided hemianopsia and color agnosia.

15.3.5. Agraphia

Agraphia - acquired impairment of the ability to write correctly in form and meaning while maintaining the necessary motor functions.

Usually combined with aphasia (except in cases of letter agnosia) and alexia. With severe manifestations of aphasia, the patient is not able to write at all; in milder cases, writing is possible, but literal and verbal paragraphs are identified, manifested by substitutions, omissions, and rearrangements of letters and words. Sometimes, usually with damage to the posterior parts of the middle frontal gyrus of the left hemisphere (field 6), isolated agraphia is noted.

15.3.6. Acalculia

If the posterior parts of the parietal-temporal region of the dominant hemisphere are damaged, acalculia is possible - a violation of the ability to carry out counting operations, especially those based on internal spatial schemes, in particular the operation of multi-digit numbers, in which the value of each digit is determined by its digit. Acalculia is often combined with semantic aphasia and optical alexia. Described by the Swedish pathologist F. Henschen (born in 1881).

15.3.7. Amnesia

Memory is a complex mental process characterized by fixation, consolidation, storage and subsequent extraction and reproduction of unconscious information and perceptions, ideas, and thoughts arising from it. Memory provides the opportunity to accumulate experience and knowledge, and contributes to the understanding of newly received information by comparing it with previously acquired information. It allows you to place all events along the time axis.

There are different types of memory: short-term (operative, fixation) and long-term, mechanical and logical (semantic), voluntary and emotional.

Memory disorder - hypomnesia or amnesia (Greek amnesia - forgetfulness, memory loss) - a violation of one or another link in the process called memory, or all its constituent elements.

It manifests itself, in particular, with Korsakoff's syndrome, described in 1889 by S.S. Korsakov in patients with alcoholism. With this syndrome, as S.S. wrote. Korsakov, “the memory of the recent is almost exclusively upset, while impressions of the past are remembered quite well.” Current information in such cases is usually stored for 2 minutes, after which it is “erased”.

There may also be disturbances in the retention of previously acquired information or its recall, retrieval, as well as the sense of time and order of past events associated with this confabulation (replacement of memory lapses with fiction, which the patient himself perceives as a probable fact), paramnesia (a general name for false memories and memory lapses).

Amnesia usually occurs with damage to the mediobasal parts of the cerebral hemispheres, especially the parahippocampus and other structures that make up the hippocampal circle, or Peipitz circle, also including the cerebral fornix, the medial structures of the thalamus and the mastoid body. Understanding how it is possible to store information in memory and retrieve it has not yet been achieved. It is assumed that the place of long-term storage of information is the protein molecules of brain cells, possibly glial cells, most likely astrocytes.

Global memory disorders are modality-nonspecific. Modality-specific forms of amnesia are also possible. The main ones are visual (figurative, iconic) and auditory amnesia, with the first of them the patient is unable to imagine a visual image of a person or object, with the second - to retain sounds, intonation, and melody in memory.

Variants of memory impairment are retrograde and antegrade amnesia, most often manifested after traumatic brain injury. Retrograde amnesia is amnesia that precedes an event, antegrade amnesia is a memory disorder that manifests itself after an event. The event that causes these disorders is usually a traumatic brain injury accompanied by loss of consciousness. Anterograde amnesia is a combination of retro- and antegrade forms of memory impairment. Episodic (periodic) amnesia is also possible.

Chronic, progressive memory loss can be combined with manifestations of dementia. This combination is typical for toxic and dyscirculatory encephalopathy, presenile and senile psychoses, in particular in Alzheimer's and Pick's diseases (see Chapter 26).

15.3.8. Other disorders of higher mental functions

It should be noted that disorders of higher mental functions are possible not only with damage to the cerebral cortex. They may be a consequence of a decrease in the level of consciousness that occurs, in particular, with damage to the

structures of the reticular formation activating the cerebral cortex at the level of the midbrain and their connections with the cortex passing through the paraventricular parts of the brain and its white matter. Disturbances of these structures underlie the syndrome of akinetic mutism, dynamic aphasia, and vegetative state.

The reason for a decrease in the level of consciousness, attention, and at the same time a narrowing of the range of interests, violations of intellectual-mnestic functions and motor activity can be not only primary lesions of the nervous system, but also somatic diseases, common infections, metabolic disorders, endogenous and exogenous intoxications.

15.4. SYNDROMES OF LARGE BRAIN DAMAGE 15.4.1. Signs of frontal lobe damage

Frontal syndrome may be a consequence of a disorder of many mechanisms involved in the formation of behavioral and higher mental functions.

When the premotor area of ​​the frontal lobes is damaged, pathological inertia, passivity, and hypokinesia are characteristic. With a more massive lesion, the mechanisms responsible for the formation of the action program also become inert. This leads to the replacement of complex motor acts with simplified, “field” forms of behavior or inert stereotypes, often combined with a “fox gait” (feet are placed on the same line, “footprint after footprint”) or with elements of frontal ataxia - Bruns ataxia (German neurologist Bruns L., 1858-1916), astasia-abasia - Block's symptom (French neurologist Bloq P., 1860-1096). Sometimes, with frontal syndrome, while walking there is a tendency for the body to deviate backward, which leads to instability of the patient and can lead to his fall - Henner's sign (Czech neurologist Henner K., 1895-1967).

Predominant damage to the basal regions and poles of the frontal lobes is accompanied by attention disorder, disinhibition, and may manifest itself in antisocial behavior.

Frontal syndrome is characterized by disorders of active perception, abstract thinking, switching from one type of action to another, while perseveration - repetition of actions (polykinesia), when speaking, repetition of the same words, when writing - words or individual letters in a word, sometimes individual elements of a letter. In such cases, in response to the task of tapping a rhythm, for example, “strong - weak - weak,” the patient performs a series of taps of uniform intensity. There is usually a decrease in criticism of one’s condition - Campbell's syndrome (Austrian neurologist Campbell A., 1868-1937) and behavior, which are determined mainly by motivations of a biological nature.

A disorder of active perception leads to the fact that the patient judges what is happening impulsively, based on random signs, and cannot differentiate the perceived information or identify the main link from it. It is difficult for him to isolate a given figure from a homogeneous background, for example, in a chess

on the blackboard, a black cross with a white center (d'Allon test, 1923), to understand the content of a complex plot picture, the assessment of which requires active analysis and comparison of details, the creation of hypotheses and their verification. The pathological process in the dominant hemisphere in Broca's area (fields 44, 45 ) usually leads to the development afferent motor aphasia, damage to the left premotor area may cause dynamic aphasia or phonetic-articulation disorders (cortical dysarthria). If the anterior part of the cingulate gyrus is affected, speech akinesia and dysphonia are possible, which during the recovery period is usually replaced by whispered and later hoarse speech.

In case of damage to the frontal lobe on the side opposite the pathological focus, it usually appears Yanishevsky-Bekhterev grasping reflex (Yanishevsky A.E., born in 1873; V.M. Bekhterev, 1857-1927) - grasping and holding an object that produces streak irritation of the skin of the palm at the base of the fingers. Tonic extension of the fingers is also possible on the foot when it is irritated with strokes - grasping Hermann's sign (Polish neuropathologist Herman E.). May also be positive symptoms of oral automatism. The combination of the grasping reflex and manifestations of oral automatism is known as Stern's sign (German neurologist Stern K.). Sometimes the grasping reflex is so pronounced that the patient has an involuntary desire to grasp objects that are at a distance and fall into the field of vision - Schuster's sign (German neuropathologist Schuster W., born in 1931). In frontal lobe syndrome, articular joints are also usually caused. Mayer's reflexes And Leri, Botez frontal reflex (Romanian neurologist Botez J., 1892-1953) - in response to line irritation of the palmar surface of the supinated hand in the direction from the hypothenar to the base of the thumb, tonic flexion of the fingers occurs, an increase in the concavity of the palm and a slight adduction of the hand; frontal Barre sign (French neurologist Barre J., 1880-1956) - prolonged freezing of the patient’s hand in the position given to it, even if this position is unnatural and uncomfortable. Sometimes there is a tendency for the patient to frequently touch the nose, reminiscent of wiping it, - Duff's sign. A sign of damage to the frontal lobe is also the femoral Razdolsky's symptom (domestic neurologist Razdolsky I.Ya., 1890-1962) - involuntary flexion and abduction of the hip in response to a pinch of the skin of the anterior surface of the thigh, as well as when tapping with a hammer on the iliac crest or on the anterior surface of the lower leg. On the side opposite to the affected hemisphere of the brain, weakness of the facial muscles is possible, more pronounced in the lower part of the face - Vincent's sign (American doctor Vensent R., born in 1906), while one can note the inexpressiveness of voluntary facial movements with intact involuntary facial expressions - Monrad-Crohn's sign.

With lesions of the cortical center of gaze, usually localized in the posterior sections of the middle frontal gyrus (fields 6, 8), and sometimes with a pathological focus quite distant from these areas of the cortex, a turn of gaze occurs in the horizontal direction, and in the most acute period (epileptic seizure , stroke, trauma), the gaze can be turned towards the pathological focus, then - usually in the opposite direction - Prevost's symptom (Swiss doctor Prevost J., 1838-1927).

Conventionally, there are two main variants of frontal syndrome: apathetic-abulic syndrome and frontal syndrome of psychomotor disinhibition.

Apatico-abulic (apathy and lack of will) syndrome characteristic of damage to the callous body, especially with frontal-callous localization of the pathological process (Bristow syndrome, described by the English neurologist Bristowe J., 1823-1895). Apathetic-abulic syndrome is a combination of passivity, lack of initiative and abulia (lack of will, indifference, which can only sometimes be partially overcome under the influence of intense external stimuli that have great personal significance for the patient). The triad characteristic of frontal callous syndrome: aspontaneity, adynamia and abulia is known as Sereysky syndrome, since it was described by the domestic psychiatrist M.Ya. Sereisky (1885-1957).

Frontal syndrome of mental disinhibition, or Bruns-Yastrowitz syndrome (German neurologists Bruns L., 1858-1916, and Jasrowitz P.) is characterized primarily by excessive disinhibition of the patient, who in his actions is guided mainly by biological motivations, ignoring ethical and aesthetic norms. Characterized by talkativeness, flat jokes, puns and witticisms, carelessness, carelessness, euphoria, loss of a sense of distance in communication with others, ridiculous actions, and sometimes aggressiveness aimed at realizing biological needs. More often observed with damage to the basal parts and poles of the brain. It may be a consequence of meningioma of the anterior cranial (olfactory) fossa or glial tumor of the anterior parts of the frontal lobes, as well as their contusion during traumatic brain injury.

With damage to the frontal lobes in patients in serious condition, it is possible parakinesis, or Jacob's sign (described in 1923 by the German neuropathologist A. Jakob, 1884-1931), in which complex automated gestures arise that outwardly resemble purposeful actions: picking, rubbing, stroking, patting, etc. With central hemiplegia, parakinesis can occur on the side of the pathological focus, which is especially typical in the acute stage of a stroke, when parakinesis can be combined with hormetonia, psychomotor agitation, which is especially typical for parenchymal-intraventricular hemorrhage.

15.4.2. Signs of damage to the parietal lobe

Damage to the postcentral gyrus is manifested by sensitivity disorders in the corresponding part of the opposite half of the body. In the case of irritation by a pathological focus, for example, an extracerebral tumor, more often a meningioma, of a section of the cortex of the postcentral gyrus in the corresponding part of the opposite half of the body, paresthesia usually occurs, manifested in the form sensitive local epileptic Jacksonian type paroxysms.

Damage to the central gyrus causes hypalgesia zones in the corresponding part of the opposite half of the body, and proprioceptive sensitivity is usually more impaired. The latter circumstance may be the cause of afferent paresis, caused by a disorder in the receipt of impulses that provide reverse afferentation. As a result, awkwardness of movements appears in the area of ​​​​disturbance of deep sensitivity, which can partly be compensated by visual control over them.

If the function of the superior parietal lobule (fields 7 and 5) is impaired, the so-called parietal paresis, which is characterized by weakness in the opposite half of the body or predominantly in a more limited part of it - in the arm (in case of damage to field 7) or in the leg (in cases of damage to field 5), parietal paresis does not extend to the facial muscles. It is characteristic of parietal paresis that muscle weakness is predominantly expressed in the distal part of the limb, the tone of the paretic muscles is somewhat reduced, tendon reflexes on the side of the paresis are not changed or are slightly increased, and pathological pyramidal signs are not detected. In the paretic part of the body, slowness and awkwardness of movements are possible, sometimes postural ataxia is clearly manifested - the patient is not able to copy with the paretic limb the movements demonstrated by the doctor in front of him. In the domestic literature, parietal paresis was described in 1951 by neuropathologist L.O. Korst.

Parietal paresis in combination with hemihypalgesia and a violation of deep sensitivity (mainly tactile and proprioceptive) in the paretic part of the body, as well as with sensory ataxia and apraxia on the side opposite the pathological focus, is known as superior parietal lobule syndrome (French neurologist Tomas A., 1867-1953).

When other areas of the parietal cortex are affected, parietal sensory syndrome, also known as Verger-Dejerine-Mouson syndrome (French doctors Verger M., born in 1915; Dejerine J., 1849-1917; as well as Mouzon P.). It consists of disorders of complex types of sensitivity caused by damage to associative zones: sense of position, localization, tactile discrimination (detected when Tauberg test), two- and three-dimensional spatial sense (stereognosis).

Inferior parietal lobule syndrome, or Krapff-Curtis syndrome (American psychiatrist Krapf E. and German doctor Curtis F., born 1896), - disorder of three-dimensional spatial sense (astereognosis, described in 1894 by the German neurologist Wernicke K., 1840-1905), spatial and constructive apraxia, a violation of the body diagram, and if the pathological focus is localized on the left - finger agnosia, manifestations of amnestic and semantic aphasia, alexia and agraphia are also possible in connection with the development of letter agnosia.

A lesion in the left hemisphere of the structures of the inferior parietal lobule adjacent to the lower part of the postcentral gyrus, which are part of the supramarginal gyrus, can cause oral apraxia and an associated speech disorder of the type of afferent motor aphasia, caused by a violation of the kinesthetic basis of movements of the articulatory apparatus.

With a pathological focus on the right, it is possible to ignore the left half of the body and the surrounding space, a feeling of extra limbs (pseudomelia), a feeling of deformation and changes in the size of the left arm and leg, a conviction of the presence of additional limbs on the left - Lenz syndrome (German psychiatrist Lenz H., born in 1912).

Sometimes, when the parietal lobe is damaged, autotopognosia occurs, manifested, in particular, by the absence of defensive reactions in response to painful stimuli - Schilder-Stengl syndrome (American physician Schilder P., 1886-1940, and Stengl K.).

In cases of damage to the parieto-occipital region of the cortex of the right hemisphere, the development of apraktoagnostichesky syndrome of G. Ekaen (described in

1956 English doctor Hecaen H.), which is a combination of left-sided spatial agnosia, autotopognosia, apractical disorders, in particular apraxia of dressing due to a violation of topographical ideas and concepts.

Damage to the cortex of the parietal-temporal region of the left hemisphere can cause a combination of sensory aphasia, letter agnosia and acalculia - Bianchi syndrome (Italian psychiatrist Bianchi L., 1848-1927). With damage to the parieto-occipital region of the dominant hemisphere, letter agnosia leading to alexia and agraphia, elements of amnestic aphasia, finger agnosia and, possibly, hemianopsia are characteristic - Dejerine syndrome (French neurologist Dejerine J., 1849-1917).

Irritation of the opercular zone and the insula of Reil is characterized by involuntary chewing movements, smacking, licking, and swallowing movements. (opercular syndrome).

15.4.3. Signs of damage to the temporal lobe

Damage to the temporal lobe of the dominant hemisphere is usually leads to speech agnosia and speech disorder of the type sensory aphasia, combined with alexia and agraphia; manifestations of semantic aphasia are less often observed. With damage to the posterior parts of the temporal lobe, letter agnosia and the resulting alexia and agraphia without aphasia, which are often combined with acalculia, are possible. Damage to the right temporal lobe may be accompanied by impaired differentiation of non-speech sounds, in particular amusia. In such cases right hemisphere pathology sometimes leads to a disorder in adequate assessment of speech intonations speech addressed to the patient. He understands words, but does not grasp their emotional coloring, which usually reflects the mood of the speaker. In this regard, they do not catch a joke or an affectionate tone of speech addressed to patients. The result may be inadequate reactions on his part to what was said.

With irritation of the temporal lobe there may be auditory, olfactory, gustatory, and sometimes visual hallucinations, which usually present an aura of seizures characteristic of temporal lobe epilepsy. Temporal lobe epilepsy can manifest itself in the form of mental equivalents, periods of ambulatory automatism, metamorphopsia - distorted perception of the size and shape of surrounding objects, in particular macro or microphotopsia, in which all surrounding objects seem too large or unnaturally small, as well as states of derealization, in which the patient has a changed attitude to reality. An unfamiliar situation is perceived as familiar, already seen (deja vu), already experienced (deja vecu), the known as unknown, never seen (jamais vu), etc. With temporal lobe epilepsy, severe autonomic disorders, inadequate emotional reactions, and progressive personality changes are common, with the epileptogenic focus often located in the medial structures of the temporal lobe.

Bilateral damage to the mediobasal parts of the temporal lobe, which are part of the hippocampal circle, is usually accompanied by memory impairment, primarily memory for current events, similar to amnesia in Korsakoff's syndrome.

When the pathological focus is localized in the deep parts of the temporal lobe on the opposite side, upper quadrant homonymous congruent (symmetrical) hemianopsia occurs, caused by damage to visual radiation. When the amygdala, located deep in the anteromedial parts of the temporal lobe, is damaged, complex changes in the emotional and mental spheres, autonomic disorders - increased blood pressure.

Famous in literature Klüver-Bucy syndrome(inability to identify objects by sight or touch and the resulting desire to grab them with the mouth in combination with emotional disorders) was described in 1938 by American researchers - neurologist H. Kluver and neurosurgeon P. Bucy, who observed this pathology in an experiment on monkeys after removal of the mediobasal parts of the temporal lobes on both sides. No one has yet seen this syndrome in a clinical setting.

15.4.4. Signs of damage to the occipital lobe

The occipital lobe provides primarily visual sensations and perceptions. Irritation of the cortex of the medial surface of the occipital lobe causes photopsia in the opposite halves of the visual fields. Photopsia may be a manifestation of a visual aura, indicating a probable occipital localization of the epileptogenic focus. In addition, the cause of photopsia may be manifestations of severe angiodystonia in the basin of the cortical branches of the posterior cerebral artery at the onset of an attack of ophthalmic (classical) migraine.

Destructive changes in one of the occipital lobes lead to complete or partial homonymous congruent hemianopia on the opposite side,

in this case, damage to the upper lip of the calcarine groove is manifested by lower quadrant hemianopsia, and the development of the pathological process in the lower lip of the same groove leads to upper quadrant hemianopsia. It should be noted that even complete (cropped) homonymous hemianopsia is usually accompanied by preservation of central vision.

Damage to the convexital cortex of the occipital lobe (fields 18, 19) can cause disturbances in visual perception, the appearance of illusions, visual hallucinations, manifestations of visual agnosia, and Balint's syndrome.

In cases of dysfunction of the thalamocortical pathways, in particular optic radiation, may appear Riddoch syndrome. It is characterized by decreased attention, impaired orientation in the area, and the ability to accurately localize visible objects. The difficulty of understanding the position of an object in space increases if the object is located on the periphery of the visual field. Patients are not aware of their defect (a kind of anosognosia). Homonymous hemihypopsia or hemianopsia are possible, but central vision is usually preserved. The syndrome was described in 1935 by the English physician G. Riddoch (1888-1947).