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The hypoglossal nucleus (CN XII) is found near the The lateral portion is supplied by the posterior inferior midline and in front of the ventricle order 8mg aceon free shipping blood pressure medication heart palpitations; its fibers exit ante- cerebellar artery buy aceon 4mg on line arteriovascular malformation, a branch of the vertebral artery (see riorly, between the pyramid and the olive (see Figure 6 Figure 58, Figure 59A, and Figure 61), called PICA by and Figure 7). CN IX and CN X are attached at the lateral neuroradiologists. This artery is prone to infarction for aspect of the medulla (see Figure 6 and Figure 7). Included in its territory are the efferent fibers are derived from two nuclei (indicated by cranial nerve nuclei and fibers of CN IX and X, the the dashed lines): the dorsal motor nucleus, which is para- descending trigeminal nucleus and tract, fibers of the ante- sympathetic, and the nucleus ambiguus, which is motor rolateral system, and the solitary nucleus and tract, as well to the muscles of the pharynx and larynx (see Figure 8A). The inferior cerebellar The dorsal motor nucleus lies adjacent to the fourth ven- peduncle or vestibular nuclei may also be involved. The nucleus ambig- whole clinical picture is called the lateral medullary uus lies dorsal to the olivary nucleus; in a single cross- syndrome (of Wallenberg). The taste and visceral afferents that are this syndrome, there is loss of the autonomic sympathetic carried in these nerves synapse in the solitary nucleus, supply to one side of the face, ipsilaterally. This leads to which is located in the posterior aspect of the tegmentum, ptosis (drooping of the upper eyelid), a dry skin, and surrounding the tract of the same name. The pupillary change is due to The reticular formation occupies the central core of the competing influences of the parasympathetic fibers, the tegmentum; the nucleus gigantocellularis is located in which are still intact. Other lesions elsewhere that inter- this part of the reticular formation (see Figure 42B). These rupt the sympathetic fibers in their long course can also cells give rise to a descending tract, the lateral reticulo- give rise to Horner’s syndrome. Cortico-spinal fibers Hypoglossal nerve (CN XII) FIGURE 67B: Brainstem Histology — Mid-Medulla © 2006 by Taylor & Francis Group, LLC 196 Atlas of Functional Neutoanatomy medial lemniscus is situated between the olivary nuclei FIGURE 67C and dorsal to the pyramids, and is oriented anteroposteri- LOWER MEDULLA: orly. Posteriorly, the fourth ventricle is tapering down in CROSS-SECTION size, giving a “V-shaped” appearance to the dorsal aspect of the medulla (see Figure 20B). It is common for the The medulla seems significantly smaller in size at this ventricle roof to be absent at this level. This is likely level, approaching the size of the spinal cord below. The accounted for by the presence of the foramen of Magendie, section is still easily recognized as medullary because of where the CSF escapes from the ventricular system into the presence of the pyramids anteriorly (the cortico-spinal the subarachnoid space (see Figure 21). Posterior to this tract) and the adjacent inferior olivary nucleus. X and CN XII, as well as the descending nucleus and tract One special nucleus is found in the “floor” of the of V, are present as before (as in the mid-medullary sec- ventricle at this level, the area postrema. The MLF and anterolateral fibers little bulge that can be appreciated on some sections. The solitary tract and nucleus nucleus is part of the system that controls vomiting, and are still found in the same location. The internal arcuate it is often referred to as the vomiting ”center. These fibers to whatever is circulating in the blood stream. It likely usually obscure visualization of the nucleus ambiguus. The dorsal aspect of the medullary tegmentum is occu- pied by two large nuclei: the nucleus cuneatus (cuneate ADDITIONAL DETAIL nucleus) laterally, and the nucleus gracilis (gracile The accessory cuneate nucleus is found at this level, as nucleus) more medially. These are found on the dorsal well as at the mid-medullary level. This nucleus is a relay aspect of the medulla (see Figure 9B and Figure 40). These for some of the cerebellar afferents from the upper extrem- nuclei are the synaptic stations of the tracts of the same ity (see Figure 55). The fibers then go to the cerebellum name that have ascended the spinal cord in the dorsal via the inferior cerebellar peduncle.

This nerve is purely motor purchase aceon 8 mg amex pulse pressure 65, and innervates the levator scapulae and rhomboid muscles (Fig discount aceon 4mg blood pressure is normally greater in your. Function: To elevate and adduct the medial border of the shoulder blade (together with the rhomboid muscles). Almost no symptoms are reported, and usually only with powerful arm move- Symptoms ments. The scapula becomes slightly abducted Signs from the thorax wall, with outward rotation of the inferior angle. Neuralgic shoulder amyotrophy Pathogenesis Iatrogenic: operations Nerve is sometimes used as a graft for nerve transplantations. EMG Diagnosis None Therapy Mumenthaler M, Schliack M, Stöhr M (1998) Läsionen einzelner Nerven im Schulter-Arm- Reference Bereich. In: Mumenthaler M (ed) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 296–311 182 Suprascapular nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + MRI, US Fig. The nerve has no cutaneous sensory distribution (Fig. Symptoms Dull, aching pain in the posterior aspect of shoulder, which is aggravated by arm use. The patient is unable to lie on his shoulder due to pain. Signs Lesion at the suprascapular notch: involvement of both muscles. Lesion at the spinoglenoid notch: only infraspinatus muscle impairment. Abnormal transverse scapular ligaments (occasionally bilateral) Causes Arthroscopic shoulder surgery Closed trauma: the most common cause Entrapment by the transverse superior or inferior ligaments Neuralgic amyotrophy Open trauma Overuse: athletic activities (basketball, volleyball, boxing) or construction trades (e. Therapy Conservative: rest the limb, analgesics, activity modification, nerve block. Replacement surgery: if the lesion appears to be permanent, a transfer from the horizontal part of the trapezoid muscle can be considered. Depends on the etiology Prognosis McCluskey L, Feinberg D, Dolinskas C (1999) Suprascapular neuropathy related to a References glenohumeral joint cyst. Muscle Nerve 22: 772–777 Mumenthaler M, Schliack H, Stöhr M (1998) Läsionen einzelner Nerven im Schulter-Arm- Bereich. In: Mumenthaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 261–368 Staal A, van Gijn J, Spaans F (1999) The suprascapular nerve. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies. Saunders, London, pp 23–25 Stewart J (2000) Nerves arising from the brachial plexus. Lippincott, Williams & Wilkins, Philadelphia, pp 157–181 184 Subscapular nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fig. The nerve innervates the subscapularis and teres major muscle, to secure the shoulder joint and provide inward rotation of the shoulder (Fig. Compensation for the function of both muscles is provided by the pectoralis Symptoms major, latissimus dorsi, and anterior deltoid muscle. Upon securing shoulder joint, an outward rotation of the upper arm. Signs Atrophy is not visible, and there are no sensory findings. Involvement either in association with radiculopathies or with posterior cord Pathogenesis brachial plexus injury.

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From the Hui-yin divide the energy into two routes buy cheap aceon 4mg on line blood pressure going up, directing the chi down the outer back portion of the left and right thigh to the l4th energy center buy generic aceon 8 mg on line arrhythmia when i lay down, the back of the knee (Wei-Chung). Next, move the energy down the outer calf to the l5th energy center, the Yin-chuan at the soles of the feet. This is the first point of the kidney channel, and concentrating at this center will strengthen the kidney, lower blood pressure, and help relieve fatigue as more energy is brought to the feet. Yung-chaun is often referred to as the “Bubbling Spring”, or the point where the yin energy bubbles up from the earth and enters the soles of the feet. Many people who concentrate on the navel feel warmth in the feet instead, because the Yung-chuan is the origin of the energy that collects in the navel. Concentrate at the soles until you feel energy there, then direct the chi to the 16th energy center which is located in the big toes. Both the liver and spleen (Ta-Tun and Yin Pai) meridians flow through the big toes and concentrating here will strengthen those organs. If you feel numbness or a pain like an ant bite, move the energy to the l7th energy center, the front of the knees (Heding). To reach the 17th energy center, the chi travels up along the shin bone to the front of the knees. The stomach and spleen chan- - 80 - Chapter VII nels pass through this region, and opening this center will strengthen these organs as well as the knee, and prepare the pas- sage for energy to go through at a later time. Be sure to draw the energy up from the earth through the soles of the feet to the knees. When you sense warmth or tingling, shift your attention back to the Hui-yin (perineum), by directing the energy along the insides of the thighs. Now send the energy to the Chang-chiang (coccyx), the Ming- men (opposite the navel), the Chi-chung (opposite the solar plexus), up to the mid-point of the scapulae. Here the energy divides into the left and right arms and de- scends to the inside of the upper arms, down to the forearms, and passes along the middle of the palm, the Lao-kun. Concentrate here for a while and then feel the energy run along to the middle finger. Then go up the outside of the forearm along the outside of the middle of the upper arms, reaching the shoulder region. Here the energy rejoins on the spine between the shoulder blades. Continuing on to the neck and up into the crown, allow the chi to descend to the tongue, where its way back to the, navel again, thereby completing the Microcosmic Orbit. The Large Heavenly Orbit is part of the Fusion of the Five Ele- ments. The second level of the Taoist Esoteric Yoga, Fusion of the Five elements, opens the other 6 psychic channels plus the Micro- cosmic (2 channels) which equals 8 channels. Someone who is sickly or weak should practice an hour in the morning, in the afternoon, and in the evening. Those who do not have back trouble, high blood pressure or gastric ulcers should do the “stretching the tendons” exercise. This is done in nine sets of nine repetititions or three sets in the morning, afternoon and evening, making a total count of 81 for the day. Just stay relaxed and if you can find a few odd minutes at home or in the office, try to meditate in those spare moments. When first beginning it takes a little bit of time and discipline to achieve rapid progress. Remember that later on it will occur with no effort. The exact amount of training and practice required to develop the Microcosmic Circulation varies from individual to individual. For best results one should practice at least twice a day at home, for ten to thirty minutes at a time, even if one has attained a higher level of accomplishment. Students with previous discipline in yoga or other meditation techniques are frequently able to open the mi- crocosmic orbit immediately by redirecting their power of concen- tration away from the “third eye” (brow point) and into the warm current flow. It is possible that some individuals might not succeed at all and never be able to grasp the essentials. Many report completion of the circulation within the first one hundred days of diligent practice.

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CNS disturbances can precede neuropathy buy aceon 8 mg without prescription heart attack 34 years old, including agitation buy cheap aceon 4 mg line arteria carotida, psychosis, Clinical syndrome/ seizures, and eventually coma. Weakness can involve the face and respiratory signs muscles. In some forms of porphyria, skin blisters can accompany an acute attack. Attacks can be precipitated by drugs that stress liver function, fasting, stress, and alcohol. Porphyria is rare and caused by disruption of heme biosynthesis. Subtypes of Pathogenesis porphyria result from dysfunction of each of the enzymes in the heme synthetic pathway, but only the subtypes that involve liver enzymes cause neuropathy. These subtypes are aminolevulinic acid dehydrase deficiency, acute intermit- tent prophyria, hereditary coproporphyria, and variegate porphyria. Diagnosis The primary diagnositic tool for an acute attack is a rapid urine test for porphobilinogen. Genetic testing is useful for exact diagnosis and for family counseling. Changes in urine color Differential diagnosis should raise suspicion of porphyria. Poisoning by lead, arsenic, or thallium can appear similar to porphyria, and even cause increases in urine porphobilino- gen. The most important treatment for an acute attack is IV heme, with attention to Therapy carbohydrate and fluid maintenance. CNS disturbances can be difficult to treat, although gabapen- tin may help control seizures. Drugs that can precipitate attacks should be avoided. Some porphyria can be triggered by hormonal changes during menstruation, and these cases can be very difficult to control. Prognosis Heme therapy is very effective at quelling acute attacks, although mortality may still be as high as 10%. Most patients recover on the whole, but severe neuropathy may be resistant because of the axonal degeneration. References Kochar DK, Poonia A, Kumawat BL, et al (2000) Study of motor and sensory nerve conduction velocities, late responses (F-wave and H-reflex) and somatosensory evoked potential in latent phase of intermittent acute porphyria. Electromyogr Clin Neurophysiol 40 (2): 73–79 Meyer UA, Schuurmans MM, Lindberg RL (1998) Acute porphyrias: pathogenesis of neurological manifestations. Semin Liver Dis 18 (1): 43–52 Muley SA, Midani HA, Rank JM, et al (1998) Neuropathy in erythropoietic protoporphyr- ias. Neurology 51 (1): 262–265 Wikberg A, Andersson C, Lithner F (2000) Signs of neuropathy in the lower legs and feet of patients with acute intermittent porphyria. J Intern Med 248 (1): 27–32 333 Other rare hereditary neuropathies Many other hereditary neuropathies have been identified, often in just a handful of families in a particular ethnic and geographic region. Several of the more common disorders are summarized in the chart below. X-linked CMT is more common than CMT-2, and Riley-Day syndrome is fairly common in Ashkenazi Jews. All are treated symptomatically and are gradually progressive. Neuropathy Genetics Clinical features CMT-3 Autosomal dominant, Severe demyelinating (Dejerine-Sottas sporadic, or recessive. Demyelinating motor and Several subclassifications sensory neuropathy with have been identified in slow NCVs. X-linked CMT X-linked dominant, more Demyelinating neuropathy severe in males. Hereditary Autosomal dominant Axonal sensory neuropathy.

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