Ñèìïàòè÷åñêàÿ ñèñòåìà
Öåíòðàëüíûå ñèìïàòè÷åñêèå ïóòè. Ñèìïàòè÷åñêèé òðàêò ìîæåò áûòü ïîâðåæäåí íà ðàçëè÷íûõ óðîâíÿõ. Ïðè ýòîì íåçàâèñèìî îò óðîâíÿ ïîðàæåíèÿ ðàçâèâàåòñÿ ñèíäðîì Ãîðíåðà.
Õàðàêòåðíûìè ÷åðòàìè ýòîãî ñèíäðîìà ÿâëÿþòñÿ:
1. Ìèîç ñî ñòîðîíû ïîðàæåíèÿ, ÿâëÿþùèé ñÿ ñëåäñòâèåì ïàðàëè÷à äèëÿòàòîðà.
2. Íàðóøåíèå ðàñøèðåíèÿ çðà÷êà â òåìíîòå.
3. ×àñòè÷íûé ïòîç, ðàçâèâàþùèéñÿ â ðå çóëüòàòå ïàðàëè÷à ìþëëåðîâñêîé ÷àñòè ëåâà- òîðà âåðõíåãî âåêà.
4. Àíãèäðîç ëèöà âñëåäñòâèå îòñóñòâèÿ ñòè ìóëÿöèè ïîòîâûõ æåëåç.
5. Ýíîôòàëüì â ðåçóëüòàòå ïàðåçà ãëàäêèõ ìûøö ãëàçíèöû, âêëþ÷àÿ ìûøöó Ìþëëåðà [454, 483].
Äåñòðóêòèâíûå ïàòîëîãè÷åñêèå ïðîöåññû, ðàçðóøàþùèå ñòðóêòóðû ìîñòà, ñïèííîãî ìîçãà, âûçâàþò îäíîñòîðîííèé ñèíäðîì Ãîðíåðà.  òî æå âðåìÿ ïðîöåññû, «ðàçäðàæàþùèå» ýòè ñòðóêòóðû, ïðèâîäÿò ê ðàçâèòèþ ñèíäðîìà Áåðíàðäà—Ãîðíåðà (Bernard—Homer), êî-
òîðûé ñâîèìè êëèíè÷åñêèìè ïðîÿâëåíèÿìè ïðîòèâîïîëîæåí ïðåäûäóùåìó. Ïðè ýòîì çðà÷îê è ãëàçíûå ùåëè ðàñøèðåíû, óâåëè÷åíî ïîòîîòäåëåíèå, ïðîñâåò ñîñóäîâ íà ñòîðîíå ïîâðåæäåíèÿ ñóæåí.
Âðîæäåííûé ñèíäðîì Ãîðíåðà ÷àñòî îáíàðóæèâàåòñÿ îäíîâðåìåííî ñ ãåòåðîõðîìèåé ðàäóæíîé îáîëî÷êè. Ïðè ýòîì ñíèæåíà ïèãìåíòàöèÿ ðàäóæêè ñî ñòîðîíû ïîðàæåíèÿ. Ãèïî-ïèãìåíòàöèÿ ñâÿçàíà ñ òåì, ÷òî ñòðîìàëüíûå ìåëàíîöèòû ñîäåðæàò íåáîëüøîå êîëè÷åñòâî çåðåí ìåëàíèíà. Ïðåäïîëàãàþò, ÷òî ðàçâèòèå ãåòåðîõðîìèè ñâÿçàíî ñ íåäîñòàòêîì òèðîçèíà-çû, íàñòóïàþùèé â ðåçóëüòàòå àäðåíåðãè÷åñêîé äåíåðâàöèè [489, 549]. Ïðè ýòîì äåïèãìåíòàöèÿ íå ðàñïðîñòðàíÿåòñÿ íà íåâóñíûå êëåòêè ðàäóæêè. Ïàðàëè÷ Êëóìïà ðàçâèâàåòñÿ ïîñëå ðîäîâîé òðàâìû â ðåçóëüòàòå ïîâðåæäåíèÿ äâèãàòåëüíûõ êîðåøêîâ.
Öåíòðàëüíûå ïîðàæåíèÿ ñèìïàòè÷åñêîé ñèñòåìû íàèáîëåå ÷àñòî ñâÿçàíû ñ îêêëþçèåé çàäíåé íèæíåé ìîçæå÷êîâîé àðòåðèè (ñèíäðîì Âàëëåíáåðãà). Ïðè ýòîì âûÿâëÿþòñÿ:
1. Ñèíäðîì Ãîðíåðà ñî ñòîðîíû ïîðàæåíèÿ.
2. Äèñôàãèÿ (ïàðàëè÷ IX, X íåðâîâ).
3. Àíàëãåçèÿ êîæè ëèöà ñî ñòîðîíû ïîðàæå íèÿ (ñïèííîé ïóòü è ÿäðà òðîéíè÷íîãî íåðâà) è àíàëãåçèÿ òóëîâèùà è êîíå÷íîñòåé ñ ïðîòèâî ïîëîæíîé ñòîðîíû (âîñõîäÿùèé ñïèííî-òàëàìè- ÷åñêèé ïóòü).
4. Ìîçæå÷êîâàÿ àòàêñèÿ ñî ñòîðîíû ïîðà æåíèÿ è ðîòàòîðíûé íèñòàãì (âåñòèáóëÿðíûå ÿäðà). Öåíòðàëüíûå òðàêòû, ëîêàëèçîâàííûå íà óðîâíå ñïèííîãî ìîçãà, íàèáîëåå ÷àñòî ïîâðåæ äàþòñÿ â ðåçóëüòàòå òðàâìû, ðàçâèòèÿ îïóõî ëåé, ñèðèíãîìèåëèè è ïðè äåìèåëèíèçèðóþùèõ çàáîëåâàíèÿõ.
Ïðåãàíãëèîíàðíûå ïîðàæåíèÿ. Ïîðàæåíèå ïðåãàíãëèîíàðíûõ âîëîêîí (êîðåøêîâûå ïîðàæåíèÿ) ìîæåò ðàçâèòüñÿ â ðåçóëüòàòå ðîäîâîé òðàâìû è àññîöèèðóåòñÿ ñ ïàðàëè÷îì ðóêè, ðàçâèâàþùåìñÿ ñî ñòîðîíû ïîðàæåíèÿ (ñèíäðîì Êëþìïêå). Îïóõîëè âåðõóøêè ëåãêîãî èëè âåðõíåé ÷àñòè ñðåäîñòåíèÿ òàêæå ïðèâîäÿò ê ïîâðåæäåíèþ ïðåãàíãëèîíàðíûõ âîëîêîí íà óðîâíå Ò, (ñèíäðîì Ïàíêîàñòà; Pancoast).  îáëàñòè øåè âîëîêíà ïîðàæàþòñÿ ïðè ðàçâèòèè îïóõîëåâûõ, âîñïàëèòåëüíûõ, òðàâìàòè÷åñêèõ çàáîëåâàíèé, óâåëè÷åíèè ëèìôàòè÷åñêèõ óçëîâ. Îïèñàíû è ñëó÷àè ïîâðåæäåíèÿ âîëîêîí ïðè ïðîâåäåíèè õèðóðãè÷åñêèõ âìåøàòåëüñòâ è êàðîòèäíîé àíãèîãðàôèè. Õàðàêòåðèçóåòñÿ ñèíäðîì ðàçâèòèåì ñèëüíûõ áîëåé â ïëå÷å, ïàðåçà è àòðîôèè ìûøö ðóêè â ñî÷åòàíèè ñ ëåãêèì ýíîôòàëüìîì, ïòîçîì è ìèîçîì. Íåðåäêî âîçíèêàþò ýðîçèè â îáëàñòè òðåòüåãî ðåáðà.
Ïîñòãàíãëèîíàðíûå ïîðàæåíèÿ. Ïîñòãàíã-ëèîíàðíûå ïîðàæåíèÿ íå ñîïðîâîæäàþòñÿ àí-ãèäðîçîì êîæè ëèöà.
Âíóòðåííÿÿ ñîííàÿ àðòåðèÿ. Àíåâðèçìû îñíîâíîãî ñòâîëà âíóòðåííåé ñîííîé àðòåðèè è åå âåòâåé âûçûâàþò ðàñøèðåíèå çðà÷êà. Ïðè
Âåãåòàòèâíàÿ (àâòîíîìíàÿ) èííåðâàöèÿ ãëàçà
ýòîì ìîãóò áûòü âîâëå÷åíû îáà êîìïîíåíòà àâòîíîìíîé íåðâíîé ñèñòåìû. Ïàðàëè÷ ñèìïàòè÷åñêîé ñèñòåìû ïðèâîäèò ê ìèîçó, óâåëè÷åíèþ ñëåçîîòäåëåíèÿ, ãîëîâíûì áîëÿì (ñèíäðîì Íîðòîíà). Ãîëîâíàÿ áîëü ìîæåò ñîïðîâîæäàòüñÿ ïòîçîì.
Ïàðàñèìïàòè÷åñêàÿ è ñèìïàòè÷åñêàÿ èííåðâàöèÿ íåðåäêî íàðóøåíà è ïðè âîñïàëèòåëüíûõ ïðîöåññàõ â îáëàñòè âåðõíåé ãëàçíè÷íîé ùåëè. Âðîæäåííûé ñèíäðîì Ãîðíåðà ðàçâèâàåòñÿ íàèáîëåå ÷àñòî ïðè ðîäîâîé òðàâìå ïëå÷åâîãî íåðâíîãî ñïëåòåíèÿ. Ïðè ýòîì íàðóøåíèå èííåðâàöèè ðàäóæêè ïðèâîäèò ê âîçíèêíîâåíèþ ãåòåðîõðîìèè â ðåçóëüòàòå íàðóøåíèÿ ïèãìåíòàöèè ïîðàæåííîãî ãëàçà.
 çàêëþ÷åíèå íåîáõîäèìî îòìåòèòü, ÷òî âûÿâèòü óðîâåíü ïîðàæåíèÿ ñèìïàòè÷åñêîé ñèñòåìû, ïðèâîäÿùèé ê ðàçâèòèþ ñèíäðîìà Ãîðíåðà, âîçìîæíî íà îñíîâàíèè èñïîëüçîâàíèÿ êîêàèíà è ãèäðîêñèàìôåòàìèíà. Ïðèáëèçèòåëüíî 90% íîðýïèíåôðèíà, âûäåëÿþùåãîñÿ â íåðâíî-ìûøå÷íûõ ñîåäèíåíèÿõ äèëÿòàòîðà ðàäóæêè, çàíîâî ïîãëàùàåòñÿ ïðåñèíàïòè÷åñêèìè îêîí÷àíèÿìè. Êîêàèí áëîêèðóåò ìåõàíèçì îáðàòíîãî ïîãëîùåíèÿ íîðýïèíåôðèíà. Ñîõðàíÿþùàÿñÿ âû-
ñîêàÿ êîíöåíòðàöèÿ íîðýïèíåôðèíà ñòèìóëèðóåò ìûøå÷íûå êëåòêè.  ðåçóëüòàòå ýòîãî ìåõàíèçìà, ó ïàöèåíòà áåç ïîðàæåíèÿ ñèìïàòè÷åñêîãî òðàêòà çðà÷îê ðàñøèðèòñÿ.  òî æå âðåìÿ ó áîëüíîãî ñèíäðîìîì Ãîðíåðà çðà÷îê ðàñøèðèòñÿ íåçíà÷èòåëüíî, ïîñêîëüêó íîðýïèíåôðèí âîîáùå íå âûñâîáîæäàåòñÿ â ïðåñèíàïòè÷åñ-êóþ ùåëü. Êàê óêàçàíî âûøå, óòî÷íèòü óðîâåíü ïîðàæåíèÿ âîçìîæíî ïðè èñïîëüçîâàíèè ãèäðîêñèàìôåòàìèíà (1% ðàñòâîð). Ãèäðîêñèàìôåòà-ìèí ñïîñîáñòâóåò âûñâîáîæäåíèþ â ïðåñèíàï-òè÷åñêóþ ùåëü íîðýïèíåôðèíà. Ïî ýòîé ïðè÷èíå ó çäîðîâûõ ïàöèåíòîâ ýòîò ïðåïàðàò ðàñøèðÿåò çðà÷îê. Ïðè ïîñòãàíãëèîíàðíîì ñèíäðîìå Ãîðíåðà îòìå÷àåòñÿ äåãåíåðàöèÿ íåðâíûõ îêîí÷àíèé. Ïî ýòîé ïðè÷èíå çðà÷îê ðàñøèðèòñÿ íåçíà÷èòåëüíî. Ïðè ïðåãàíãëèîíàðíîì ñèíäðîìå Ãîðíåðà ïîñòãàíãëèîíàðíûé íåéðîí ñîõðàíÿåòñÿ, â ñâÿçè ñ ÷åì ïðè ââåäåíèè ãèäðîêñèàìôåòàìèíà çðà÷îê ðàñøèðÿåòñÿ. Èñïîëüçîâàíèå àíàëèçà ðåàêöèè çðà÷êà ïðè ïðîâåäåíèè èññëåäîâàíèÿ ñ èñïîëüçîâàíèåì êîêàèíà è ãèäðîêñèàìôåòàìèíà â äîñòàòî÷íî áîëüøîì ÷èñëå ñëó÷àåâ ìîæåò óòî÷íèòü óðîâåíü ïîðàæåíèÿ, ÷òî èìååò áîëüøîå êëèíè÷åñêîå çíà÷åíèå (ðèñ. 4.5.15).
Ýôôåðåíòíûé
ñèìïàòè÷åñêèé
òðàêò
Ïðåãàíãëèî-íàðíûå âîëîêíà
Ïîñòãàíãëèî-íàðíûå âîëîêíà
Áàçîâàÿ
Êîêàèí
Ýïèíåôðèí
Ãèäðîêñè-àìôåòàìèí
Ñèíäðîì Ãîðíåðà:
— ïòîç;
— ìèîç;
— ýíîôòàëüì;
— ðàñøèðåíèå ñîñóäîâ;
— îòñóòñòâèå ñåêðåöèè
Ðèñ. 4.5.15. Ñòðóêòóðíàÿ îðãàíèçàöèÿ ñèìïàòè÷åñêîé èííåðâàöèè ãëàçà è ãëàçíèöû è îñîáåííîñòè ðåàêöèè çðà÷êà íà ðàçëè÷íûå ôàðìàêîëîãè÷åñêèå ïðåïàðàòû ïðè ïîâðåæäåíèè ñèìïàòè÷åñêîãî òðàêòà:
âåðõíÿÿ ñòðîêà òàáëèöû èëëþñòðèðóåò ñîñòîÿíèå çðà÷êà ïðè ïîâðåæäåíèè ñèìïàòè÷åñêîãî òðàêòà íà ðàçëè÷íûõ óðîâíÿõ äî ïðèìåíåíèÿ ïðåïàðàòîâ. Îñòàëüíûå òðè ñòðîêè èëëþñòðèðóþò èçìåíåíèå ðàçìåðà çðà÷êîâ ïðè èíñòèëëÿöèè êîêàèíà, ýïèíåôðè-íà è ãèäðîêñèàìôåòàìèíà. Îáðàùàåò íà ñåáÿ âíèìàíèå òî, ÷òî èñïîëüçîâàíèå ãèäðîêñèàìôåòàìèíà ïîçâîëÿåò ÷àùå (íà 16%) äèôôåðåíöèðîâàòü ïîñò-ãàíãëèîíàðíûå ïîðàæåíèÿ îò ïðåãàíãëèîíàðíûõ (/ — ïîäáóãîðíàÿ îáëàñòü (ãèïîòàëàìóñ); 2 — ìîñò; 3 — ïðîäîëãîâàòûé ìîçã; 4 — ïîäêëþ÷è÷íàÿ àðòåðèÿ; 5 — âíóòðåííåå ñîííîå ñïëåòåíèå; 6 — íàðóæíûå ñîííûå âîëîêíà; 7 — ñîííàÿ àðòåðèÿ)
Ãëàâà 4. ÃÎËÎÂÍÎÉ ÌÎÇÃ È ÃËÀÇ
Ëèòåðàòóðà
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