Professor, West Virginia University School of Medicine
This is a pure motor disorder of the muscles of articulation and may be a result of flaccid or spastic paralysis arteria vesicalis purchase midamor line, rigidity blood pressure readings low midamor 45mg on-line, repetitive spasms (stuttering) arteria 60 purchase 45mg midamor visa, or ataxia hypertension 39 weeks pregnant cheap midamor 45 mg with amex. The terms dysarthria and anarthria are applied to this category of speech disorder. An alteration or loss of voice because of a disorder of the larynx or its innervation-aphonia or dysphonia. Chapter 28 fully considers the important but sepa rable category of developmental disorders of speech and language. The main receptive area, subserv ing the perception of spoken and probably of internal lan guage, occupies the posterosuperior temporal area (the posterior portion of area 22) and Heschl gyri (areas 41 and 42). The posterior part of area 22 in the planum tem porale is referred to as Wernicke area. The perisylvian language areas are also connected with the striatum and thalamus and with corresponding areas in the nondominant cerebral hemisphere through the corpus callosum and anterior commissure. Having indicated the main regions involved with language, there remains considerable difference of opin ion concerning the status of cortical language areas, and objection has been made to calling them "centers," for they do not represent histologically or circumscribed I I Broca area with the lower rolandic cortex, which, in tum, structures of constant function. Knowledge of the anatomy of language has come almost exclusively from the postmortem study of humans with focal brain diseases. One has subdivided the language zone into separate afferent (auditory and visual) receptive parts, connected by identifiable tracts to the executive (efferent-expressive) centers. Depending on the exact location of the lesions, a number of special syndromes are elicited. The other broad theory, advanced originally by Marie (he later claims to have changed 23-1. Dia gram of the brain showing the classic language areas, numbered according to the scheme of Brodmann. The elabo ration of speech and language probably depends on a much larger area of cerebrum, indicated roughly by all the shaded zones (see text). Note tha t areas 41 and 42, the primary audi tory receptive areas, are shown on the lateral surface of the temporal lobe but extend to its superior surface, deep within the syJyjan fissure. Figure area occupies the angular gyrus (area 39) in the inferior his mind) and supported by Head, Wilson, Brain, and Goldstein, favored the idea of a single language mecha nism, roughly localized in the opercular, or perisylvian region of the dominant cerebral hemisphere. The aphasia in any particular case was presumed to be a result of the summation of damage to input or output modalities rela tive to this central language zone. Undeniably, there is recognizable afferent and efferent localization within the perisylvian language area, as discussed above, but there is also an undifferentiated central integrative mass action, in which the degree of deficit is to a considerable extent influenced by the size of the lesion. In addition, a strict division of aphasias into expressive and receptive, while still a strong practical concept, is not fully borne out by clinical observation. Nevertheless, there are several local izable language functions in the perisylvian cortex. Carl Wernicke more than any other person must be credited with the anatomic-psychologic scheme upon which many contemporary ideas of aphasia rest. Earlier, Paul Broca (1865), and, even before him, Dax (1 836), made the fundamental observations that a lesion of the insula and the overlying operculum deprived a person of speech and such lesions were always in the left hemi sphere. The supramarginal gyrus, which lies between these auditory and visual language "centers," and the inferior temporal region, just anterior to the visual association cortex, are probably part of the language apparatus as well Here are located the integrative centers for cross-modal visual and auditory language functions. The main executive, or output, region, situated at the posterior end of the inferior frontal convolution (Brodmann areas 44 and 45), is referred to as Broca area and is concerned with motor aspects of speech. In some models of language, visually perceived words are given expression in writing through a fourth language area, the so-called Exner writing area in the posterior part of the second frontal convolution. However, this latter concept is controversial in view of the fact that widely separated parts of the language zone may cause a disproportionate disorder of writing. In any case, there are two parallel systems for understanding the spoken word and produc ing speech and for the understanding of the written word and producing writing. These sensory and motor language areas are intri cately connected with one another by a rich network of nerve fibers, one large bundle of which, the arcuate fasciculus, passes through the isthmus of the temporal lobe and around the posterior end of the sylvian fissure; other connections may traverse the external capsule of the lenticular nucleus (subcortical white matter of the insula). Many additional corticocortical connections lead into the perisylvian zones and project from them to other parts of the brain. Wernicke gave a comprehensive description of the receptive, or sensory, aphasia that now bears his name. The four main features he pointed out were (1) a disturbance of comprehension of spoken language and been somewhat disappointing. Functional magnetic resonance imaging (2) of written language (alexia), (3) agraphia, and (4) flu ent paraphasic speech. Studies of blood flow and topographic physiology during the acts of reading and speaking, while generally affirming nineteenth-century models of language, have shown widespread activation of Wernicke and Broca areas, as well as of the supple mentary motor area and areas of the opposite hemisphere (see Price). Although localization o f the lesion that produces aphasia is in most instances roughly predictable from the clinical deficit, there are wide variations. The incon sistency has several explanations, one being that the net effect of any lesion depends not only on its locus and extent but also on the degree of cerebral dominance, i. According to this view, a left-sided lesion has less effect on language function if cerebral dominance is poorly established than if dominance is strong. In all likelihood, the variability between patients in lesion location and the characteristics of aphasia has to do with subtle differences in the organization of the lan guage cortices. Another explanation invokes the poorly understood concept that individuals differ in the ways in which they acquire language as children. This is believed to play a role in making available alternative means for accomplishing language tasks when the method initially learned has been impaired through brain disease. The extent to which improvement of aphasia represents "recovery" of function or generation of new modes of response has not been settled. Careful case analyses since the time of Broca and Wernicke have borne out these associa tions between a receptive (Wernicke) type of aphasia and lesions in the posterior perisylvian region and between a predominantly (Broca) motor aphasia and lesions in the posterior part of the inferior frontal lobe and the adja cent, insular, and opercular regions of the frontal cortex.
Syndromes
Brain damage
Try bending forward at the waist slightly to make it easier for you to breathe.
Incoordination
Shiny, red or purple eyelid
Vasculitis or periarteritis nodosa
Ifosfamide (Ifex)
Preschooler test or procedure preparation (3 to 6 years)
Testicle ultrasound
Factors that may precipitate the necrosis or hemorrhage of a pituitary tumor are anticoagulation fitbit prehypertension buy midamor amex, pituitary func tion testing blood pressure quick reduction order generic midamor line, radiation heart attack or stroke order midamor visa, bromocriptine treatment blood pressure tracking chart excel buy generic midamor 45mg online, and head trauma; most cases, however, occur spontaneously. Ischemic necrosis of the pituitary, without the presence of a tumor followed by hypopituitarism, occurs under a variety of circumstances, the most common being in the partum or postpartum period (Sheehan syndrome). M e n i n g i o m a of the S p h e n o i d R i d g e this tumor, mentioned earlier in the chapter, i s situated over the lesser wing of the sphenoid bone. Fully 75 percent of such tumors occur in women, and the average age at onset is 50 years. Most prominent among the symptoms are a slowly devel oping unilateral exophthalmos, slight bulging of the bone in the temporal region, and radiologic evidence of thick ening or erosion of the lesser wing of the sphenoid bone. Variants of the clinical syndrome include anosmia; oculo motor palsies; painful ophthalmoplegia (sphenoidal fissure and Tolosa-Hunt syndromes; see Table 47-2); blindness and optic atrophy in one eye, sometimes with papilledema of the other eye (Foster Kennedy syndrome); mental changes; seizures ("uncinate fits"); and increased intracranial pres sure. Sarcomas arising from skull bones, metastatic carcinoma, orbitoethmoidal osteoma, benign giant cell bone cyst, tumors of the optic nerve, and angiomas of the orbit must be considered in the differential diagnosis. The tumor is resectable without further injury to the optic nerve if the bone has not been invaded. M e n i n g i o m a of the O l fa ct o ry G roove this tumor originates in arachnoidal cells along the crib riform plate. The diagnosis depends on the finding of ipsilateral or bilateral anosmia or ipsilateral or bilateral blindness-often with optic atrophy and mental changes. The tumors may reach enormous size before coming to the attention of the physician but as many are small and found incidentally with cerebral imaging. The unilateral visual disturbance may consist of a slowly developing central scotoma. Abulia, confusion, forgetfulness, and inappropriate jocularity (witzelsucht) are the usual psychic disturbances from compression of the inferior frontal lobes (see Chap. M e n i n g i o m a of the Tu b e rc u l u m S e l l a Cushing was the first to delineate the syndrome caused by this tumor. The pre senting symptoms were visual failure-a slowly advanc ing bitemporal hemianopia with a sella of normal size. Often the field defects are asymmetrical, indicating a combined chiasmal-optic nerve involvement. If removal is incomplete or the tumor recurs or undergoes malignant changes, radiation therapy of one type or another is indicated. The outlook is then guarded; several of our patients succumbed within a few years. G l i o m a of the B ra i n ste m Astrocytomas of the brainstem are relatively slow-grow ing tumors that infiltrate tracts and nuclei. They produce a variable clinical picture depending on their location in the medulla, pons, or midbrain. Most often, this tumor begins in childhood (peak age of onset is 7 years), and 80 percent appear before the twenty-first year. Symptoms have usually been present for 3 to 5 months before com ing to medical notice. In most patients the initial mani festation is a palsy of one or more cranial nerves, usually the sixth and seventh on one side, followed by long tract signs-hemiparesis, unilateral ataxia, ataxia of gait, para paresis, and hemisensory and gaze disorders in addition to pseudobulbar dysarthria and palsy. Patients in the latter group survive longer than those whose illness begins with cranial nerve palsies. The course is slowly progressive over several years unless some part of the tumor becomes more malignant (anaplastic astrocytoma or glioblastoma multiforme) or, as rarely happens, spreads to the menin ges (meningeal gliomatosis), in which instance the illness may terminate fatally within months. The main problem in diagnosis is to differentiate this disease from a pontine form of multiple sclerosis, a vascular malformation of the pons (usually a cavern ous hemangioma), or brainstem encephalitis, and to distinguish the focal from the diffuse type of glioma (see below). A study of 87 patients by Barkovich and coworkers emphasized the importance of distinguishing between diffusely infiltrating and focal nodular tumors. These diffusely infiltrating tumors, usually showing an asymmetrical enlargement of the pons, have a poorer prognosis than the focal or nodular tumors, which tend to occur in the dorsal brainstem and Figure 3 1 -21. The patient was a 3-year-old male with progressive crania] nerve and long tract deficits. In a few instances of diffuse brainstem glioma, surgical exploration is neces sary to establish the diagnosis (inspection and possibly biopsy). A series of 16 patients treated by Pollack and colleagues emphasizes that the focal and exo phytic brainstem tumors are almost all low-grade astro cytomas; these tumors, in contrast to the more diffuse type, usually respond well to partial resection and permit long-term survival because they recur only slowly and do not undergo malignant transformation. Gangliocytomas or mixed astrogangliocytomas are rare imitators of nodu lar glioma in the brainstem. Landolfi and colleagues emphasized the longer survival in adults with pontine glioma (median 54 months) as compared to children. Most of the patients with pontine tumors with which we are familiar proved to have malignant gliomas. G l i o m a of the O ptic N e rves and C h i a s m impossible to distinguish from optic nerve gliomas and should be followed closely. Chordoma this tumor, like the brainstem glioma, occurs most fre quently during childhood and adolescence. The initial symptoms are dimness of vision with constricted fields, followed by bilateral field defects of homonymous, heteronymous, and sometimes bitemporal type and progressing to blindness and optic atrophy with or without papilledema. Hypothalamic signs (adi posity, polyuria, somnolence, and genital atrophy) occur occasionally as a result of proximal tumor extension. This finding and the lack of ballooning of the sella or of suprasellar calcification will exclude pituitary adenoma, craniopharyngioma, Hand-Schuller-Christian disease, and sarcoidosis. In ado lescents and young adults, the medial sphenoid, olfactory groove, and intraorbital meningiomas (optic nerve sheath meningioma) are other tumors that cause monocular blindness and proptosis.
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One has but to observe the resemblances between parent and child to confirm this view heart attack diet cheap midamor master card. Just as no two persons are physi cally identical blood pressure medication depression order midamor 45 mg free shipping, not even monozygotic twins hypertension lab tests order midamor discount, so hypertension over 65 buy discount midamor 45 mg online, too, do they differ in any other refined quality one chooses to measure, particularly those that determine behavior and modes of thinking. Strictly speaking, the normal person is an abstraction, just as is a typical example of any disease. It is in nonphysical attributes that individuals dis play the greatest differences. Here reference is made to their variable place on a scale of energy, capacity for effective work, sensitivity, temperament, emotional responsivity, aggressivity or passivity, risk taking, ethi cal sense, flexibility, and tolerance to change and stress. The sources of these social reactions are even more obscure than those of tem perament, character, and intelligence. In children, difficulty in social adaptation tends first to be manifest by an inability to take their places in a classroom. The development of adult gonadal function and the further evolution of psychosex ual impulses create a bewildering array of new challenges in social adaptation. As social roles change, as intellectual and physical capacities first advance and later recede, new challenges demand new adaptations. The most severe forms of delayed motor development, those associated with spasticity and athe tosis, are usually manifestations of prenatal and perinatal diseases of the brain subsumed under the term cerebral palsy; these are discussed in Chap. In assessing developmental abnormalities of the motor system in the neonate and young infant, the fol lowing maneuvers, which elicit certain postures and reflexive movements, are particularly useful: 1. A loud noise, slapping the bed, or jerking one leg will have the same effect, causing an elevation and abduction of the arms followed by a clasping movement to the midline. This response is present in newborns and infants, it wanes after 2 months and is no longer elicitable after about 5 months of age, and its absence before that time or persistence afterwards indicates a disorder of the motor system. An absent or inadequate Moro response on one side is found in infants with hemiplegia, bra chial plexus palsy, or a fractured clavicle. Persistence of the Moro response beyond 4 or 5 months of age is noted only in infants with severe neurologic defects. The tonic neck reflex consisting of extension of the arm and leg on the side to which the head is passively turned and flexion of the opposite limbs, if obligatory and sustained, is a sign at any age of pyramidal or extrapyramidal motor abnormality. Barlow reports that he has obtained this reflex in 25 percent of devel opmentally delayed infants at 9 to 10 months of age. Fragments of the reflex, such as a brief extension of one arm, may be elicited in 60 percent of normal infants at 1 to 2 months of age and may be adopted spontaneously by the infant up to 6 months of age. As with the Moro response, persistence beyond this age represents a malfunction of the nervous system. The placing reaction in which the foot or hand, brought into contact with the edge of a table, is lifted automatically and placed on the flat surface, is pres ent in all normal newborns. Its absence or asymmetry in infants younger than 6 months of age indicates a motor abnormality. In the Landau maneuver, the infant, if suspended hor izontally in the prone position, will extend the neck and trunk and will break the trunk extension when the neck is passively flexed. This reaction is present by age 6 months; its delayed appearance in a hypo tonic child is indicative of a faulty motor apparatus. If an infant is held prone in the horizontal position and is then dropped toward the bed, an extension of the arms is evoked, as if to break the fall. This is known as the parachute response and is elicitable in most 9-month-old infants. The detection of gross delays or abnormalities of motor development in the neonatal or early infantile period of life is aided little by tests of tendon and plantar reflexes. Arm reflexes are always rather difficult to obtain in infants, and a normal neonate may have a few beats of ankle clonus. However, a consistent extension of the great toe and fanning of the toes on stroking the side of the foot is abnormal at any age. The early detection of cerebral palsy is hampered by the fact that the corticospinal tract is not fully myelinated until 18 months of age, allowing only quasivoluntary movements up to this time. For this reason, a congenital hemiparesis may not be evident until many months after birth. Even then it is manifest only by subtle signs, such as holding the hand in a fisted posture or clumsiness in reaching for objects and in transferring them from one hand to the other. Later, the leg is seen to be less active as the infant crawls, steps, and places the foot. Early hand dominance should always raise the suspicion of a motor defect on the opposite side. In the upper limb, the charac teristic catch and yielding resistance of spasticity is most evident in passive abduction of the arm, extension of the elbow, dorsiflexion of the wrist, and supination of the forearm; in the leg, the change in tone is best detected by passive flexion of the knee. However, the time of appear ance and degree of spasticity are variable from child to child. The stretch reflexes are hyperactive, and the plantar reflex may be extensor on the affected side. With bilateral hemiplegia, the same abnormalities are detect able, but there is a greater likelihood of pseudobulbar manifestations, with delayed, poorly enunciated speech. Later, intelligence is likely to be impaired (in 40 per cent of hemiplegias and 70 percent of bilateral hemiple gias). In diparesis or diplegia, hypotonia gives way to spasticity and the same delay in motor development except that it predominates in the legs. Aside from the hereditary spastic paraplegias, which may become evident in the second and third years, the common causes of weak spastic legs are prematurity and matrix hemorrhages.
