Kortikale Repräsentation des Schluckaktes – Neues zur Physiologie und Pathophysiologie des Schluckens

Zusammenfassung

Im Gegensatz zur seit vielen Jahren etablierten klinischen Bedeutung der neurogenen Dysphagie ist die Aufklärung der zentralen Koordination des Schluckaktes Gegenstand der aktuellen Forschung. Während sogenannte Schluckzentren des Hirnstammes den unwillkürlichen Schluckreflex steuern, kommt dem zerebralen Kortex eine entscheidende Bedeutung bei der willkürlichen Initiierung des Schluckaktes zu. Der physiologische Schluckakt wird bilateral im sensomotorischen Kortex und in mehreren weiteren kortikalen und subkortikalen Hirnregionen verarbeitet. Klinische Beobachtungen bei Schlaganfallpatienten und neue bildgebende Studien legen eine Hemisphärenspezialisierung für einzelne Phasen des Schluckaktes nahe. Dabei werden eine vorwiegend linkslateralisierte Verarbeitung der oralen Phase und eine rechtshemisphärische Lateralisation der pharyngealen Phase angenommen. Auch für pathologische und iatrogene Veränderungen konnten bereits Anpassungs- und Kompensationsmechanismen nachgewiesen werden. Läsionen des ersten Motoneurons führen zu einer Abnahme der kortikalen schluckakt-assoziierten Aktivität. Bei unilateraler Läsion, wie z. B. beim Schlaganfall, können parallel zur klinischen Erholung Reorganisationsprozesse beobachtet werden. Schädigungen jenseits des ersten Motoneurons, z. B. infolge einer bulbospinalen Muskelatrophie, resultieren typischerweise in einer Vergrößerung der kortikalen Repräsentation des Schluckaktes. Wir nehmen an, dass die bisherigen Resultate zukünftig bei der Entwicklung neuer Therapien und deren Evaluation von großem Wert sein werden.

Abstract

In spite of the long established clinical relevance of neurogenic dysphagia, clarification of the central control of deglutition is the object of ongoing research. While central swallowing pattern generators in the brainstem control the involuntary swallowing reflex, the cerebral cortex plays a decisive role in the voluntary initiation of deglutition. Physiological deglutition is processed bilaterally in the sensorimotor cortex and in several additional cortical and subcortical brain regions. Clinical observations in stroke patients and recent imaging studies suggest hemispheric specialisations for the different phases of deglutition. Predominantly left lateralised processing of the oral phase and right hemispheric lateralisation of the pharyngeal phase are assumed. Adaptation and compensation mechanisms have moreover been shown for pathological and iatrogenic changes. Lesions of the upper motor neuron result in a decrease of swallowing-related cortical activation. In the case of unilateral affection as in stroke, reorganisation processes can be observed parallel to clinical recovery. Lesions beyond the upper motor neuron, e.g., bulbospinal muscle atrophy, typically result in an increase of the cortical representation of swallowing. We assume that the hitherto existing results will be of value for the development of new therapies and their evaluation.

Schlüsselwörter

kortikale Verarbeitung - Schlucken - Dysphagie - funktionelle Bildgebung - MEG

Key words

cortical processing - swallowing - dysphagia - functional imaging - MEG

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