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A 16-year-old boy is brought to the family physician by his or power of a movement and is commonly seen in cerebellar dis- mother buy generic rumalaya liniment 60 ml on-line. Dysarthria is difficulty in speaking purchase rumalaya liniment 60 ml otc, and dyspnea is a difficulty school even though he is a hard worker and is well behaved buy rumalaya liniment 60 ml low price. The in breathing; the latter is usually associated with diseases of the examination reveals that the boy has a sensorineural hearing loss lungs or heart order rumalaya liniment 60 ml free shipping. Which of the following alternating movements, is seen most commonly in cerebellar dis- represents the most likely location of the lesion in this boy? Answer E: One possible cause of trigeminal neuralgia (tic (B) Cochlea douloureux) is compression of the trigeminal root by the superior (C) External ear cerebellar artery or its main branches; surgical relocation of the (D) Inferior colliculus aberrant vessel (neurovascular decompression) relieves the symp- (E) Middle ear toms. Hemifacial spasm may be caused by compression of the fa- cial nerve by the anterior inferior cerebellar artery (commonly 84. Which of the following laminae of the lateral geniculate nucleus called AICA). The other choices do not cause trigeminal neuralgia receive input from the contralateral retina? Answer E: The rostral interstitial nucleus of the medial longitu- (D) 2, 3, 5 dinal fasciculus receives cortical input from the frontal eye field on (E) 3, 4, 5, 6 the ipsilateral side and projects to the ipsilateral (heavy) and con- tralateral (light) oculomotor and trochlear nuclei. A 12-year-old girl is brought to the pediatrician by her mother regarded as the vertical gaze center. The paramedian pontine who explains that the girl has started to “act funny”. The oculomotor reveals that the girl was treated for a hemolytic streptococcus in- and abducens nuclei do not receive direct input from the frontal fection 4 weeks before the appearance of her symptoms; the eye field and the Edinger-Westphal is a visceromotor nucleus con- mother states that the girl has had this problem for 3 weeks. Answer C: The absence of, or the aberrant development of, This girl is most likely suffering from which of the following? Mesoderm of the (E) Weber syndrome head outside of the pharyngeal arches gives rise to the extraocular muscles and muscles of the tongue. The muscles of mastication Q & A’s: A Sampling of Study and Review Questions with Explained Answers 287 (plus the tensor tympani, tensor veli palati, mylohyoid, anterior ing of written or printed words. Aphonia is a loss of the voice fre- belly of the digastric) arise from arch 1, the stylopharyngeus from quently due to disease of, or injury to, the larynx. Aphasia is seen arch 3, and striated muscles of the pharynx, larynx, and upper in individuals with a lesion in the dominant hemisphere, and is esophagus from arch 4. Answer C: Hypothalamocerebellar fibers that project to the cerebellar nuclei and cortex contain histamine. Answer C: The Korsakoff syndrome is a constellation of deficits several neurons that are located in the cerebellar cortex, and in the include memory loss, confabulation, amnesia, and dementia Purkinje cells glutamate is found in many pontocerebellar fibers that is seen in chronic alcoholics; the manifestations are related, in and in granule cells of the cerebellar cortex; and noradrenalin is part, to excessive alcohol consumption and malnutrition. Serotonin is found in cells of the peutic doses of thiamine are used to treat this disease. Broca apha- reticular formation and in some raphe cells that project to the sia (nonfluent or expressive aphasia) results from lesions in the cerebellum. The Klüver-Bucy syndrome is related to bilateral lesions to the amygdaloid complex, and Pick disease is de- 8. Answer C: The best localizing sign in this patient is the paucity mentia related to atrophy of the frontal and temporal lobes. Mun- of eye movement and dilated pupil on the left; this indicates a le- chausen syndrome is the fabrication or feigning of illness or disease sion of the midbrain on the left at the level of the exiting oculo- to gain attention or control. The red nucleus is found at the same level and, more importantly, immediately lateral to the red nucleus is a compact 14. Answer B: Cell bodies in the nucleus ambiguus innervate mus- bundle of cerebellothalamic fibers. The ataxia and tremor are re- cles of the pharynx and larynx, including what is commonly called lated primarily to damage to these cerebellar efferent fibers.

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Examples of spike ac- tivity occurring singly and in a spike-and-wave pattern are shown in Figure 7 generic rumalaya liniment 60 ml on line. The ascending reticular activating system is pe- wave riodically shut down by influences from other regions of the reticular formation order rumalaya liniment 60 ml. The EEG recorded during sleep re- 100 µV veals a persistently changing pattern of wave amplitudes 1 sec and frequencies purchase rumalaya liniment 60 ml on line, indicating that the brain remains continu- 0 ally active even in the deepest stages of sleep cheap 60 ml rumalaya liniment fast delivery. The EEG pat- Patterns of brain waves recorded on an tern recorded during sleep varies in a cyclic fashion that re- FIGURE 7. Wave patterns are designated alpha, peats approximately every 90 minutes, starting from the beta, theta, or delta waves, based on frequency and relative ampli- time of falling asleep to awakening 7 to 8 hours later (Fig. These cycles are associated with two different forms pear as many neurons are activated simultaneously. Rapid eye movement (REM) sleep: back-and-forth alertness scale, when sensory input is at its lowest, in deep movements of the eyes under closed lids, accompanied by sleep, a synchronized EEG has the characteristics of low fre- autonomic excitation quency and high amplitude. An absence of EEG activity is EEG recordings of sleeping subjects in laboratory set- the legal criterion for death in the United States. Corpus callosum A normal sleep cycle begins with slow-wave sleep, four Frontal lobe stages of increasingly deep sleep during which the EEG be- Lateral comes progressively slower in frequency and higher in am- ventricle plitude. Stage 4 is reached at the end of about an hour, Cerebral Basal when delta waves are observed (see Fig. The subject cortex ganglia then passes through the same stages in reverse order, ap- proaching stage 1 by about 90 minutes, when a REM period begins, followed by a new cycle of slow-wave sleep. Slow- Sylvian wave sleep is characterized by decreased heart rate and fissure blood pressure, slow and regular breathing, and relaxed muscle tone. Stages 3 and 4 occur only in the first few sleep Anterior cycles of the night. In contrast, REM periods increase in du- Temporal commissure ration with each successive cycle, so that the last few cycles lobe consist of approximately equal periods of REM sleep and The cerebral hemispheres and some deep FIGURE 7. The corpus callosum is the major commissure of the seeming contradictions in its characteristics. The anterior the EEG exhibits unsynchronized, high-frequency, low- commissure connects rostral components of the right and left amplitude waves (i. The cortex is an outer rim of gray matter (neu- cal of the awake state than sleep, yet the subject is as diffi- ronal cell bodies and dendrites); deep to the cortex is white mat- ter (axonal projections) and then subcortical gray matter. Second, the autonomic nervous system is in a state of excitation; blood pressure and heart rate are increased and breathing is irregular. In males, autonomic excitation in REM sleep in- columns perpendicular to the surface. This reflex is used in diagnosing im- neurons give rise to descending fiber tracts and intrahemi- potence, to determine whether erectile failure is based on a spheric and interhemispheric fiber tracts, which, together neurological or a vascular defect (in which case, erection with ascending axons coursing toward the cortex, make up does not accompany REM sleep). A deep sagittal fissure divides the cortex into a usually report dreaming. Accordingly, it is customary to con- right and left hemisphere, each of which receives sensory sider REM sleep as dream sleep. Another curious characteris- input from and sends its motor output to the opposite side tic of REM sleep is that most voluntary muscles are tem- of the body. Two exceptions, in addition to the interconnects the two hemispheres, so that processed neu- muscles of respiration, include the extraocular muscles, ral information from one side of the forebrain is transmitted which contract rhythmically to produce the rapid eye move- to the opposite hemisphere. The largest of these commis- ments, and the muscles of the middle ear, which protect the sures is the corpus callosum, which interconnects the major inner ear (see Chapter 4). Muscle paralysis is caused by an ac- portion of the hemispheric regions (Fig. In certain sleep disorders in which skele- ordinating motor activity (see Chapter 5).

In chronic denervation proven rumalaya liniment 60 ml, the muscle edema re- Achilles fat pad solves discount 60 ml rumalaya liniment amex, and the involved muscles undergo volume loss fat pad (Fig buy rumalaya liniment 60 ml low price. Other common accessory muscles include the peroneus quartus muscle best rumalaya liniment 60 ml, behind the fibula, the accessory abductor digiti minimi, in the wrist, and the anomalous lumbrical muscle, seen in carpal tunnel. Congenital Muscular Disorders There are numerous forms of muscular dystrophy, with Duchenne and Becker muscular dystrophy being the most common. These typically present with progressive proximal muscle weakness in childhood or adoles- cence. The congenital myopathies all involve multiple muscle groups, typically in a symmetrical fashion. In the acute phase of muscle damage, symmetrical mild hyperintensity of the muscles can be seen (Fig. An axial fat-suppressed pro- ton-density (PD)-weighted image of the proximal calf shows a gan- sues remain normal. More advanced disease typically glion adjacent to the proximal tibiofibular joint. Due to compres- shows pseudohypertrophy of lower extremity muscles, sion on the peroneal nerve, denervation changes are apparent in the particularly the calf musculature, due to excessive fat- tibialis anterior muscle Fig. An axial STIR MR image of the thighs shows symmetrical hyperintensity of the quadriceps muscles 50 M. The presence of fatty change implies an Pyomyositis irreversible lesion. Clinical history and the distribution of the muscle abnormalities, which correspond to a specific Deep cellulitis can be associated with septic fasciitis or nerve distribution, allow accurate diagnosis of muscle pyomyositis, an infiltrative deep infection of muscle. Pyomyositis used to be seen most frequently in children and in patients from the tropics. More recently, py- omyositis has been recognized with increasing frequency Atrophy in adult patients with AIDS. Atrophy of muscle is the result or end stage of many mus- The most common causative organism is Staphylococcus cle abnormalities, so it is only a finding, not a diagnosis. Pyomyositis Chronic disuse, denervation, and myopathies are the most is typically limited to one muscle group. Adjacent soft tissue in- flammation may be present, but subcutaneous inflammato- ry changes are minimal compared to those seen in patients Autoimmune Myopathies with cellulitis or fasciitis, and are disproportionately less prominent than the muscular abnormalities. The underlying Polymyositis is the classic autoimmune inflammatory bony cortex and bone marrow are typically not involved. When associated with skin changes, the same On T1-weighted MR, findings are minimal except for syndrome is called dermatomyositis. Numerous other subcutaneous edema and mild enlargement of the affect- forms of autoimmune muscle inflammation are recog- ed muscles due to the increased volume of interstitial flu- id and fluid collections. The autoimmune muscle disorders produce sym- ial in the center of an abscess may show intermediate sig- metrical muscle weakness that primarily involves the nal intensity on T1-weighted images, either diffusely or proximal muscles. High signal intensity is seen within the mus- cle inflammation is the most prominent finding. Adjacent soft-tissue flamed muscles are edematous but the normal muscle ar- inflammation is typically present. Myositis is more often unilateral or asymmetrical in association with collagen vascular disease than it is with idiopathic polymyositis. This middle-aged HIV-positive male present- of the calf shows widespread feathery muscle edema and mild sub- ed with a swollen painful thigh and fever. Note the preservation of the normal muscle ar- shows subcutaneous and patchy muscle enhancement, as well as a chitecture small focal abscess in the vastus lateralis Magnetic Resonance Imaging of Muscle 51 Muscle Injury Fig. This man injured both legs during Fascial Herniation a soccer game and developed medial thigh pain immediate- ly after the injury. A PD- Herniation of muscle through an overlying fascial tear is weighted fat-suppressed an uncommon injury that presents as a painful mass. The coronal image of the thighs mass can be seen to enlarge or contract with muscle con- shows high signal intensity localized around the my- traction, allowing accurate diagnosis. Muscle herniation otendinous junction of the ad- through fascial tear is very difficult to see with MR; we ductor muscles bilaterally, prefer to use US for this diagnosis, because the mass can consistent with a low-grade be examined during dynamic muscle contraction.

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