The Wallenberg-Zakharchenko Syndrome

In medicine, there are a number of diseases, called alternating medullary syndromes of the brain stem. One of the most common among them is the Wallenberg-Zakharchenko syndrome. The disease was described as early as 1895 by Dr.-psychotherapist Adolf Wallenberg. Subsequently, after 16 years, another neuropathologist MA Zakharchenko supplemented the description of pathology.

The Wallenberg-Zakharchenko syndrome is characterized by a lesion of the posterolateral region of the medullary part of the tire localized at the level of the medulla oblongata. The affected structures are represented by the double core (9, 10 nerves), the core of the path of the spinal cord (5 nerve), the sympathetic fibers of the Budge center, the rope body, the medial loop, the vestibular nuclei (8 nerve), etc.

Next, we offer you a description of the classical development of the Wallenberg-Zakharchenko syndrome.

Wallenberg-Zakharchenko Altering Syndrome

Such pathologies, collectively referred to as alternating syndromes, have received this name from the term "alternans", which in Latin means "opposite". These include the Wallenberg-Zakharchenko syndrome, as well as other syndromes accompanied by the defeat of the cranial nerves against the background of central motor paresis and hypoesthesia in the opposite half of the trunk. Since the paresis affects both the body and the limbs, it is called hemiparesis, and the analogous sensory disturbances that occur by analogy are hemihypesthesia. Because of the specifics of clinical features, alternating syndromes in neuropathology are also called "cross symptom complexes."

Neurologists identify a number of such cross-symptom complexes. Among them - bulbar (associated with lesions of the medulla oblongata), pontine (associated with the defeat of the bridge) and peduncular (defect-related brain legs) disorders. The Wallenberg-Zakharchenko syndrome in this perspective refers to bulbar diseases.

Epidemiology

Especially often, Wallenberg-Zakharchenko syndrome develops as a result of ischemic stroke. When the intracranial zone of the vertebral artery is occluded, there are stable alternating signs of damage to the medulla oblongata and transient signs of ischemia of the oral sections of the brainstem, the temporal and occipital lobe. The Wallenberg-Zakharchenko syndrome develops in about 75% of such cases.

The syndrome is diagnosed mainly in patients older than 50 years, regardless of gender.

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Causes of the Wallenberg-Zakharchenko syndrome

The most common cause of the development of the Wallenberg-Zakharchenko syndrome is thrombosis of the posterior cerebellar artery (branches of the vertebral artery), as well as a deficit of blood flow in the vertebral-basilar basin.

The basis for painful processes can be as follows:

• Stroke is the most common cause that provokes the development of the syndrome. So, the etiological factor in ischemic stroke is thromboembolism, the spastic condition of the system of arterial vessels (in particular, the vertebral, cerebral, basilar artery). About hemorrhagic stroke, they say, when there is a hemorrhage from these arteries.
• Tumor process in the brain can directly affect the trunk, or be located next to it, putting pressure on the stem structures.
• Inflammatory reactions in the brain - encephalitis, abscess, meningitis, with spread to stem tissues.
• Head trauma, craniocerebral injury - in particular, fractures of the cranial bones, which are involved in the formation of the posterior cranial fossa.
• Poliomyelitis, syphilis.

Risk factors

There are external and internal factors that can affect the development of the Wallenberg-Zakharchenko syndrome:

• age over 50;
• violations of the blood coagulation system;
• high cholesterol in the blood;
• bad habits - smoking and drinking alcohol;
• head trauma;
• hereditary pathologies;
• obesity, diabetes mellitus;
• septic complications;
• long-term use of oral contraceptive drugs, hormone therapy;
• chemotherapy;
• severe recovery postoperative stage;
• sedentary lifestyle;
• forced long uncomfortable position of the body and limbs;
• severe temperature changes, prolonged hypothermia, thermal shock;
• malignant formations;
• diseases of the cardiovascular system;
• stress, instability of the nervous system.

Pathogenesis

The oblong brain is small in size, as well as a complex anatomical structure and a large functional load. Even minor painful foci in it lead to the appearance of various clinical signs - one-sided or bilateral. In abnormalities of the medulla oblongata, abnormalities in the functional ability of 9-12 pairs of cranial nerves are found. The disease is also characterized by pyramidal movement disorders, changes in sensitivity in the face and body, malfunctioning of the cerebellum, vasomotor system, and other disorders of the autonomic nervous system.

The defeat of the medulla oblongata is often observed against a background of vascular, inflammatory or tumor pathologies related to the nervous system. The direct flow of blood into the medulla oblongata happens rarely: the Wallenberg-Zakharchenko syndrome is more often caused by softening of the brain structures - for example, in case of poliomyelitis. Such a defeat is most dangerous, because of the high risk of paralysis of the respiratory system.

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Symptoms of the Wallenberg-Zakharchenko syndrome

The classic course of the Wallenberg-Zakharchenko syndrome is determined by such symptomatology:

• dysfunction of the musculature of the soft palate with vocal cords;
• unilateral impairment of motor coordination in the cerebellum type;
• symptom complex (triad) of Horner (Bernard-Horner): ovulation of the upper eyelid, abnormal narrowing of the pupil, sagging of the eyeball;
• dissociated sensitivity disorder (mainly the middle and caudal zones of the Zelder are affected).

The course of the disease may be somewhat different, depending on the pathology variant (we described them below).

The first signs of the Wallenberg-Zakharchenko syndrome are quite typical:

• disturbed swallowing;
• broken speech (right up to utter impossibility to speak);
• partial loss of functionality of the soft palate;
• immobilization of the vocal cords;
• triad Gorner (ptosis, miosis, enophthalmus);
• vestibular-cerebellar disorders ("empty" motor activity of limbs, trembling, loss of balance, nystagmus);
• pain in the head or face (partial or complete).

The listed clinical features are explained by the overlap of the posterior cerebellar arterial vessel, which entails necrosis of the outer oblong brain, the trigeminal nerve exit zone and the fibers of the sympathetic system.

Stages

Classification of the Wallenberg-Zakharchenko syndrome by stages is not always appropriate, so it is not used by many specialists. Nevertheless, it exists and consists of four stages of the pathological process:

1. Acute period of the Wallenberg-Zakharchenko syndrome.
2. Early recovery period of the patient, with the formation of necrosis areas and the development of collateral blood flow.
3. Late period of recovery, with the formation of scar tissue changes.
4. The period of residual phenomena of the Wallenberg-Zakharchenko syndrome.

Forms

The Wallenberg-Zakharchenko syndrome develops as a result of occlusion of the posterior cerebellar artery. The disease is manifested by paresis or paralysis of the soft palate with a voice ligament, defeat of sympathetic fibers and trigeminal nerve (segmental type), cerebellar disorders (ataxia, nystagmus). On the opposite side, pain and temperature sensitivity are lost, movements are disturbed in the form of paralysis or paresis formation.

Neuropathologist MA Zakharchenko identified a number of pathology variants:

1. The first version of the Wallenberg-Zakharchenko syndrome proceeds with the development of paralysis of the soft palate with a voice ligament and a deviation of the tongue in the opposite direction to the affected one. There is a symptom complex of Horner, a loss of the palatine and pharyngeal reflex, electrical excitability of the soft-tissue muscles deteriorates, swallowing and speech are broken, the pain and temperature sensitivity of the part of the face disappears from the pathology. There are violations of trophism of the skin of the auricle, a herpetic rash appears, dryness and flaking of the skin in the hair growth zone and on the face, an atrophic rhinitis develops. On the healthy side, there are dissociated violations of pain and temperature sensations on the body and limbs.
2. The second variant of the Wallenberg-Zakharchenko syndrome differs somewhat from the first variant. When the pathological process spreads to the upper structures to the bridge, 6-7 cranial nerves are damaged. The Horner symptom is fixed, coordination and statics are violated, a paresis of the voice ligament appears with a soft sky. On the opposite side, hemianesthesia is recorded.
3. The third variant of the course of the Wallenberg-Zakharchenko syndrome is characterized by paralysis of a part of the soft palate with a voice ligament and a deviation of the tongue in the opposite direction. There is no pharyngeal and palatal reflex, swallowing and speech are broken, Horner's symptom complex is observed, sensitivity of one side of the face is violated, trophism of cutaneous and mucous membranes worsens. Atrophic rhinitis, locomotor ataxia develops, statics are disrupted. Detection slows the heart rate, taste changes on one side of the tongue. The patient is worried about dizziness (sometimes with vomiting), nystagmus towards the affected area. On the opposite side, a dissociated malfunction of sensitivity on the body and extremities is recorded.
4. The fourth variant of the course of the Wallenberg-Zakharchenko syndrome is observed when the process spreads to the descending sections up to the intersection of the pyramidal pathways. There is a paresis of the soft palate with a voice ligament, Gorner's symptom complex, limb coordination and statics are broken, cross-triplegia (or hemiplegia) is detected, and alternating sensory disorder (in the area of lesion on the face, on the opposite side on the body and limbs).

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Complications and consequences

With the Wallenberg-Zakharchenko syndrome, as with all alternating syndromes, serious complications can occur. With spastic hemiparesis, joint contractures develop, which only aggravate motor disorders. With paresis of the nerves, there is a violation of the symmetry of the face, which becomes a significant aesthetic problem. With unilateral paresis of the oculomotor group, there is a dichotomy that adversely affects the function of vision.

The most dangerous complications develop against the backdrop of progression of pathology, with the spread of the process to the brain regions responsible for respiratory and cardiovascular functionality.

The quality of patient recovery depends on many factors, and it is almost impossible to predict the subsequent development of events and the outcome of Wallenberg-Zakharchenko syndrome in advance.

[4], [5], [6]

Diagnostics of the Wallenberg-Zakharchenko syndrome

Determine the presence of the Wallenberg-Zakharchenko syndrome is already possible during the examination of a neurologist. Obtained visual information allows you to put a preliminary diagnosis, establishing the localization of the problem. According to the characteristics of the course of the disease, one can approximately imagine the etiology of the syndrome. Therefore, often differential diagnosis is carried out at the time of the initial medical examination.

For tumor processes is characterized by a steady increase in symptoms for a couple of months (in some cases - even a few weeks).

In inflammatory processes, mainly common intoxication symptoms are observed: high fever, weakness, drowsiness, dry mucous membranes, etc.

With strokes, the alternating syndrome always develops sharply, with a rapid increase in symptoms along with a change in blood pressure.

In hemorrhagic stroke, there is an atypical picture of the alternating syndrome, which can be explained by the fuzziness of the restriction of the painful focus due to pronounced perifocal reactions (puffiness, reactive symptoms).

To clarify the cause of the development of the Wallenberg-Zakharchenko syndrome, the doctor prescribes additional diagnostics.

Instrumental diagnostics includes such procedures:

• Magnetic resonance imaging of the brain (helps to examine the inflamed area, the place of hemorrhage, the tumor process, the zone of a stroke, to distinguish between hemorrhagic or ischemic stroke, to evaluate the severity of pressure on the stem structures).
• Transcranial dopplerography of cerebral vessels (reveals disorders of cerebral circulation, symptoms of thromboembolism, local spasm of cerebral vessels).
• Ultrasound examination of extracranial vessels (helps to diagnose occlusion of vertebral and carotid arteries).

Analyzes of blood and urine are carried out in the general order, however they are of little informative in diagnosing the Wallenberg-Zakharchenko syndrome. It is possible to perform lumbar puncture - if infectious-inflammatory pathology is suspected. With infectious inflammation, the cerebrospinal fluid will be turbid, an increased content of cellular elements will be observed due to neutrophils, and bacteria will also be detected. Additional bacteriological and virological analyzes will help to identify the pathogen.

[7], [8], [9]

Treatment of the Wallenberg-Zakharchenko syndrome

It is necessary to begin treatment of the Wallenberg-Zakharchenko syndrome as early as possible. The main goal of such treatment is to normalize the function of vital organs and brain areas, as well as to eliminate tissue edema and stabilize blood circulation.

Common measures include the use of decongestants and neuroprotectors, as well as tools that correct blood pressure indicators. When forming a thrombus, thrombolytic, vascular therapy is prescribed.

In general, the initial therapy for the Wallenberg-Zakharchenko syndrome consists of the following stages:

• oxygen inhalations, artificial respiration;
• stabilization of arterial pressure (Magnesium sulfate, Enap, Metoprolol);
• elimination of cerebral edema (L-lysine, Furosemide, Mannitol);
• correction of nutrition of nerve cells (Piracetam, Cavinton, Neurobion, Ceraxon, Neuromax, etc.);
• the introduction of thrombolytics or anticoagulants (Aktilis, Heparin, Clexan);
• symptomatic therapy with the use of analgesics, anti-inflammatory drugs, antibiotics.

The rehabilitation period is controlled by a general team of such specialists as a rehabilitologist, a chiropractor, a physician, physiotherapist.

Medications for the Wallenberg-Zakharchenko syndrome

	Dosing and Administration	Side effects
Metoprolol	In an acute period, the drug is administered intravenously, in individual doses (analog Betalok). In the future, if necessary, take inside 100-150 mg per day for 1-2 reception.	Bradycardia, palpitations, fatigue, dizziness, nausea, shortness of breath.
Furosemid	Enter injectively, in an individually selected dose, taking into account the recommended daily average dosage of 1500 mg.	Violations of electrolyte balance, arterial hypotension, nausea, acute pancreatitis, pruritus, urticaria.
Neurobion	Enter intramuscularly, in an acute period - one ampoule per day, then - one ampoule 1-3 times a week.	Nerve agitation, dizziness, nausea, abdominal pain.
Kleksan	Enter subcutaneously, in an individually selected dosage, under the control of blood coagulation properties.	Hemorrhagic episodes, headache, allergic reactions.
Heparin	Enter intravenously or subcutaneously, in individual dosages. For 1-3 days before the drug cancellation, indirect anticoagulants are prescribed.	Thrombocytopenia, pain in the head, increased levels of hepatic transaminases, osteoporosis, skin rash.

Vitamins and Nutritional Features

The diet of patients who have been diagnosed with Wallenberg-Zakharchenko syndrome should be maximally vitaminized. It should consist of fruits, vegetables, cereals, berries, dairy products and vegetable oils. The daily menu includes products containing dietary fiber - to normalize the function of the intestines and prevent the increase in cholesterol.

It is important to eat foods with high levels of omega-3 fatty acids. They are present in fish (mackerel, tuna, salmon), fish oil, and help to prevent thrombus formation and stabilize blood circulation.

It is also recommended to consume more foods that contain vitamin E: wheat sprouts, vegetable oils (linseed, olive), flaxseed, sunflower seeds, avocado. Vitamin E has the properties of an antioxidant. It strengthens blood vessels, improves immunity, prevents the development of coronary heart disease.

Exclude from the diet margarine, fatty meat products, smoked products, confectionery.

The decision about the use of additional vitamins of complex chemist's medications is taken by the attending doctor. An additional intake of nicotinic acid, folic acid, vitamins B ₆  and B ₁₂ may be recommended .

Physiotherapeutic treatment

To obtain the most optimal therapeutic result for patients who underwent Wallenberg-Zakharchenko's syndrome, specific variants of physical exertion involving the affected area are used. With the help of such an influence, it is possible to eliminate puffiness, restore damaged vessels and brain tissue.

Modern methods allow you to influence the area that suffered most from the syndrome. Stimulation of blood circulation and nutrition of tissues is especially necessary for the speedy rehabilitation of the patient.

Physiotherapy in this case has the following objectives:

• restoration of speech activity;
• regulation of physical activity (restoration of coordination and some lost functions).
• Among the most effective methods of physical impact can be identified:
• Electrophoresis, against the background of parallel treatment of medicines. The duration of one session can be 10-30 minutes.
• Electromyostimulation helps restore blood circulation and blood supply to affected areas. The procedures are carried out for a long course, until the patient's condition is permanently improved.
• Darsonvalization, is used to activate the basic processes in the damaged limbs.
• Magnetic therapy, increases the body's resistance to diseases, normalizes vascular tone, accelerates vascular blood flow, expands the capillary system.

In addition, for the recovery of the body after the Wallenberg-Zakharchenko syndrome, vibrating massage, cold and thermal procedures, applicative application of paraffin to the affected areas, and the use of ozocerite compresses are often prescribed. Excellent reviews were received from patients who took therapeutic baths with coniferous and salt extracts.

Alternative treatment

During the acute period of the Wallenberg-Zakharchenko syndrome, the patient should be treated only in a hospital setting. At the rehabilitation stage, when the functional capacity of the organism is restored, it is allowed to conduct home treatment, using traditional and alternative medicine. So, alternative healers offer to accelerate the recovery of such recipes:

• Grind 1 tsp. Crushed rhizome of peony, insist in 200 ml of boiling water for an hour. Take 1 tbsp. L. Funds every three hours.
• Take a warm bath with the addition of decoction of the rhizome of cinnamon dogrose. Such procedures are conducted once in two days, the course is expected to hold at least 25 procedures.
• Pour 200 ml of boiling water 1 tbsp. L. Spruce needles, insist for an hour, filtered. Add juice from half a lemon and take on an empty stomach a little during the day. The course of treatment - at least 60 consecutive days.
• Take a mummy in the amount of 2 g at bedtime, for 28 days. Next, you should take a break 10 days, after which the course can be resumed.
• Mix 5 pieces of pine needles with 2 parts of onion husks and 2 parts of rose hips. Pour 2 tbsp. L. Mixture of 1 liter of water, boil for 10 minutes, then poured into a thermos bottle and held for 10-12 hours. The resulting preparation is prepared daily and drunk during the day instead of water or tea.
• Mix 100 g of honey and the same amount of onion juice. Take the drug for 1 tbsp. L. After each meal. Store in the refrigerator.

During the entire recovery period, patients are recommended to include dates and raw quail eggs in the diet.

Herbal Treatment

• Mix 100 grams of chamomile, St. John's wort, immortelle and birch buds. Pour into the pan 10 g of the mixture, pour 500 ml of boiling water, stand for 30 minutes, filter. Take 200 ml of infusion overnight, with one teaspoon of honey, and also in the morning 30 minutes before the first meal.
• Make a mixture of lemon balm, heather, hawthorn, oregano, hips, rose hips and a pimple. 500 ml of boiling water and 40 g of mixture are steamed in a thermos bottle. Drink the infusion throughout the day. The course of treatment is 2 months.
• In 200 ml of boiling water pour 1 tbsp. L. Sage, taken inside instead of tea. Also take a bath with a decoction of sage (300 g of plant per 10 liters of water).
• Take equal parts of the roots of valerian, peony and cyanosis. Pour 20 g of the mixture with one liter of water, boil for 30 minutes on low heat, and filter. Take before going to sleep 100 ml, daily.
• The rhizomes of the sorrel are cut, poured with vodka (1 part of the root into 10 parts of vodka), insist 3 weeks. Filter and take 40 drops with water three times a day.

Homeopathy

In the recovery period after the Wallenberg-Zakharchenko syndrome, the homeopathic doctor can recommend treatment with one or more homeopathic remedies. The main goal of such treatment is to restore lost functions and improve the quality of life of the patient. For example, the patient can be offered such homeopathic medicines:

• Likopodium of clavatum - restores the motor abilities of the limbs;
• Calcium fluoride - stabilizes metabolic processes, improves the condition of blood vessels;
• Arnica - accelerates tissue regeneration, especially suitable for left-sided lesion;
• Lachezis is a "left-sided" drug that improves microcirculation in the affected parts of the brain;
• Bottrops is a "right-sided" drug that improves blood flow to tissues and accelerates blood clot resorption;
• Bufo-wound - helps to restore the disturbed speech function, has calming properties;
• Latyrus sativus - restores the motor abilities of the lower limbs;
• Glebborus niger - clarifies the consciousness of the patient, relieves retardation;
• Nux vomica - improves the work of the nervous system, restores the functionality of the abdominal cavity and small pelvis.

Among the complex homeopathic remedies for the Wallenberg-Zakharchenko syndrome, the following are often used:

• Ubihinon compositum (Heel) - allows to restore trophic and nerve conduction. Enter the drug intramuscularly, 2.2 ml 1-3 times a week, for 2-5 weeks;
• Cerebrum compositum - prevents cerebral circulatory disorders, accelerates the regeneration of brain tissue. The drug is administered intramuscularly, 2.2 ml up to three times a week, for 3-6 weeks;
• Eskulus compositum - normalizes the vascular circulation, stimulates the recovery of nerve structures. The drug is taken 10 drops three times a day, about 15 minutes before meals, for 4-6 weeks.

Preparations are selected by a specialist, based not only on the existing symptoms, but also on the overall well-being of the patient, on his constitutional features.

Surgery

• Carotenoid endarterectomy.

This operation involves the removal of the inner lining of the affected arterial vessel along with the thrombus formed inside it. Such intervention allows to minimize the risk of repeated lesions of the brain: most often it is indicated if the narrowing of the artery lumen exceeds 70%, or in the diagnosed chronic cerebral circulation deficiency. Surgical access to the site of intervention is in the neck area. One of the risks of this operation is the separation of the thrombus from the artery wall with the further development of ischemic stroke. To avoid such a complication, the surgeon introduces into the lumen of the artery an original "filter".

• Operation of angioplasty and stenting.

Both of the above methods are usually combined with each other. The essence of angioplasty is as follows: a special catheter is introduced into the lumen of the affected area of the arterial vessel (more often through the lead vessel, with obligatory radiographic observation). Then, at the end of the catheter, a balloon is inflated, which helps to widen the lumen of the vessel. Carry out angioplasty of the affected arteries. Then proceed to stenting: they establish a special structure in the form of a framework that fixes the lumen of the vessel and prevents the formation of blood clots in it.

Prevention

Prevention of the Wallenberg-Zakharchenko syndrome should be carried out in a comprehensive manner and in several ways. First and foremost, it is desirable to determine the probability of hereditary predisposition, to carry out a gene-molecular and biochemical study of blood. Especially relevant is the conduct of a thorough diagnosis of those people who have factors that involve the risk of increased thrombosis. For example, a high degree of risk is unambiguously present in patients who previously had episodes of uncaused or repeated thrombosis that appeared after minor provoking factors: minor traumatic injuries, pregnancy, etc.

The main measures that will help to avoid the development of the Wallenberg-Zakharchenko syndrome are:

• providing moderate physical exertion, with the exception of excessive activity and hypodynamia (optimal walking walks in the green zone - in the park, park, in the forest);
• daily use of a sufficient amount of liquid, wearing comfortable clothes;
• prevention of infectious pathologies, hardening procedures, strengthening of immune defense, a full-fledged vitaminized diet;
• refusal to smoke and abuse of alcoholic beverages;
• Elimination of prolonged exposure to scorching sunlight, in hot or cold conditions;
• periodic preventive vitamin therapy, taking anticoagulants (if there are indications).

Forecast

The outcome of the disease largely depends on how timely the balls are provided to the patient with medical care. Delay with hospitalization leads to the fact that the patient becomes disabled - less than 20% of such people will be able to live longer than five years.

Emergency care for a patient with Wallenberg-Zakharchenko syndrome should be provided in the first 2-3 hours, beginning with the appearance of the first sign of pathology. Only in this situation a person can save his life and achieve a further relative restoration of lost functions. The probability of complete healing is no more than 2-3%.

The following signs indicate the possible unfavorable forecast:

• development of the syndrome of the "locked" person (deferentation syndrome), in which the patient's adequate reaction to any external stimuli is lost due to tetraplegia and paralysis of bulbar, mimic and masticatory muscles;
• disturbances of respiratory, cardiovascular and thermoregulatory functions;
• the presence of neurologic disorders for 12 months or more.

As a rule, the Wallenberg-Zakharchenko syndrome leads to the fact that the patient becomes an invalid.