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Professor, Western Michigan University Homer Stryker M.D. School of Medicine
Conversely bacteria under fingernails erythromycin 500 mg amex, administering a serotonin agonist (such as sumatriptan succinate [Imitrex]) often relieves the headache antibiotics no dairy buy 500mg erythromycin fast delivery. Medical research has demonstrated that individuals suffering from migraines are actually at less risk for stroke than the general population (Bannister antibiotic resistance vs tolerance generic erythromycin 250mg with mastercard, 1992) bacteria que come el cerebro purchase erythromycin 250 mg without prescription. The following sections review diagnostic procedures that are used to document stroke. Over time, the circumference of the lesions becomes more irregular and the lesion less dense. Angiography can also provide an evaluation of collateral vessel potential and a diagnosis of coexisting neurologic problems. Angiography is an invasive diagnostic procedure that entails some risk (see Chapter 2). The two most common routes for angiography are via the venous and arterial systems (see review in Chapter 2). Arterial angiography is more popular in diagnosing stroke, because it provides precise images of cerebral arteries. This is because the specialist can pass the catheter, which injects the contrast medium, up the aortic arch and selectively place it into the carotid or vertebral arteries. Angiography can also show whether the obstructing lesion is significantly impairing carotid blood flow and whether the lesion can be removed surgically. These devices, which use ultrasonic waves, function on the principle that extensive lesions to the carotid arteries may produce distorted sound-wave feedback. In addition, pulse-wave Doppler imaging systems may be sensitive to blood flow velocity. In most cases, a conclusive diagnosis is not made; rather, noninvasive devices for carotid blood flow serve to screen for subsequent referral to the more invasive angiogram. These include the extent of the lesion, the general health of the cerebrovascular system, the presence of collateral circulation in the brain, and the location of the lesion. These factors influence the extent and nature of associated cognitive symptoms, as well as the possibility and prognosis for recovery and extent of rehabilitation. S i z e o f B l o o d Ve s s e l If a small blood vessel (such as a capillary) is interrupted, the effects are more limited than the often devastating consequences of damage to a large vessel, such as the internal carotid artery or other cerebral arteries. Strokes of these large arteries can result in lesions that include large portions of the brain and produce serious behavioral deficits, coma, and even death. In addition, the presence of collateral blood vessels allows redundant blood supply to take more than one route to a given region. The term collateral is used to describe redundant blood flow present in the vascular network after occlusion of an artery. If one vessel is blocked, a given region may be spared an infarct because the blood has an alternative route to the affected brain area. This communication between blood vessels by collateral channels is also known as anastomosis and provides an important defense against stroke. The properties of collateral communication that provides a sufficient blood supply to obstructed areas vary considerably among individuals. Thus, damage to the same vessel in different people can produce symptoms that vary considerably. Anastomosis can provide some relief to blood-depleted brain areas, particularly if the primary vessel affected is gradually blocked, rather than rapidly occluded. A small stroke in an otherwise healthy brain will, in the long run, have a good prognosis for substantial recovery of function. As a result, destruction of a functional zone of brain tissue may produce serious consequences for the patient. Location the location of brain tissue involved in a vascular disorder has neuropsychological significance. A lesion in the temporal lobe can produce a deficit in understanding speech; a stroke in the hippocampus can cause memory deficits; and a lesion in the brainstem can trigger heart failure, resulting in death. Thus, behavioral symptoms of vascular disorder are important clues to the neuropsychologist for locating the area of brain damage and assessing the extent of damage. Common medications include anticoagulants to dissolve blood clots or prevent clotting, vasodilators to dilate or expand vessels, and blood pressure medication and steroids to control cerebral edema. Surgeons have developed interventions to reduce the risk for bleeding for some aneurysms by "clipping" them (Figure 12. Other surgical procedures are used in the case of hemorrhages when it may be necessary to operate to relieve the pressure of the blood from the ruptured vessel on the rest of the brain.
Syndromes
- Herpes zoster
- A broken bone
- Dialysis (if severe kidney problems are present)
- Male factor infertility, including decreased sperm count and blockage
- Bleeding into an area around the brain (also called a subarachnoid hemorrhage)
- Selenium excess
- Subarachnoid hemorrhage
- Endoscopy -- camera down the throat to see burns in the esophagus and the stomach
- Liver failure
Particular attention should be paid as to whether a specific tract crosses the midline to the opposite side of the central nervous system or remains on the same side bacteria jokes for kids 250mg erythromycin with visa. The assessment of neurologic damage requires not only an understanding of the main nervous pathways within the spinal cord but an ability to correlate radiologic evidence of bone injury with segmental levels of the spinal cord antimicrobial yahoo 250mg erythromycin overnight delivery. The close relationship of the spinal cord to the bony vertebral column necessitates a brief review of the vertebral column before the spinal cord is considered antibiotic 825 buy erythromycin 500 mg online. It supports the skull antibiotics xanax interaction generic erythromycin 500mg on-line, pectoral girdle, upper limbs, and thoracic cage and, by way of the pelvic girdle, transmits body weight to the lower limbs. Within its cavity lie the spinal cord, the roots of the spinal nerves, and the covering meninges, to which the vertebral column gives great protection. A typical vertebra consists of a rounded body anteriorly and a vertebral arch posteriorly. These enclose a space called the vertebral foramen, through which run the spinal cord and its coverings. The vertebral arch consists of a pair of cylindrical pedicles, which form the sides of the arch, and a pair of flattened laminae, which complete the arch posteriorly. The vertebral arch gives rise to seven processes: one spinous, two transverse, and four articular (Fig. The spinous process, or spine, is directed posteriorly from the junction of the two laminae. The transverse processes are directed laterally from the junction of the laminae and the pedicles. Both the spinous and transverse processes serve as levers and receive attachments of muscles and ligaments. The articular processes are vertically arranged and consist of two superior and two inferior processes. The two superior articular processes of one vertebral arch articulate with the two inferior articular processes of the arch above, forming two synovial joints. The pedicles are notched on their upper and lower borders, forming the superior and inferior vertebral notches. On each side, the superior notch of one vertebra and the inferior notch of an adjacent vertebra together form an intervertebral foramen. These foramina, in an articulated skeleton,serve to transmit the spinal nerves and blood vessels. The anterior and posterior nerve roots of a spinal nerve unite within these foramina with their coverings of dura to form the segmental spinal nerves. Joints of the Vertebral Column Below the axis the vertebrae articulate with each other by means of cartilaginous joints between their bodies and by synovial joints between their articular processes. Because it is segmented and made up of vertebrae, joints, and pads of fibrocartilage called intervertebral discs, it is a flexible structure. Joints Between Two Vertebral Bodies Sandwiched between the vertebral bodies is an intervertebral disc of fibrocartilage (Fig. General Characteristics of a Vertebra Although vertebrae show regional differences, they all possess a common pattern (Fig. The surface marking of the external occipital protuberance of the skull, the ligamentum nuchae (solid black line) and some important palpable spines (solid dots) are also shown. Each disc consists of a peripheral part, the anulus fibrosus, and a central part, the nucleus pulposus (Fig. The anulus fibrosus is composed of fibrocartilage, which is strongly attached to the vertebral bodies and the anterior and posterior longitudinal ligaments of the vertebral column. It is normally under pressure and situated slightly nearer to the posterior than to the anterior margin of the disc. The upper and lower surfaces of the bodies of adjacent vertebrae that abut onto the disc are covered with thin plates of hyaline cartilage. The semifluid nature of the nucleus pulposus allows it to change shape and permits one vertebra to rock forward or backward on another. A sudden increase in the compression load on the vertebral column causes the nucleus pulposus to become flattened, and this is accommodated by the resilience of the surrounding anulus fibrosus.
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Lateral to the gracile tubercle is a similar swelling antibiotics for acne and alcohol trusted 500mg erythromycin, the cuneate tubercle antibiotics simplified pdf 250mg erythromycin otc, produced by the underlying cuneate nucleus antibiotics and weed discount erythromycin 500mg on line. Internal Structure As in the spinal cord virus 68 michigan cheap 250 mg erythromycin,the medulla oblongata consists of white matter and gray matter, but a study of transverse sections of this region shows that they have been extensively rearranged. This rearrangement can be explained embryologically by the Internal Structure 199 expansion of the neural tube to form the hindbrain vesicle, which becomes the fourth ventricle (Fig. The extensive lateral spread of the fourth ventricle results in an alteration in the position of the derivatives of the alar and basal plates of the embryo. To assist in understanding this concept, remember that in the spinal cord, the derivatives of the alar and basal plates are situated posterior and anterior to the sulcus limitans, respectively, and in the case of the medulla oblongata,they are situated lateral and medial to the sulcus limitans, respectively (Fig. The internal structure of the medulla oblongata is considered at four levels: (1) level of decussation of pyramids, (2) level of decussation of lemnisci, (3) level of the olives, and (4) level just inferior to the pons. See Table 5-2 for a comparison of the different levels of the medulla oblongata and the major structures present at each level. Level of Decussation of Pyramids A transverse section through the inferior half of the medulla oblongata. In the superior part of the medulla, the corticospinal fibers occupy and form the pyramid, but inferiorly, about three-fourths of the fibers cross the median plane and continue down the spinal cord in the lateral white column Neuroepithelial layer Neural crest cells Roof plate Marginal layer Alar plate Cavity of neural tube Posterior gray column White matter Mantle layer Gray matter A Sulcus limitans B Basal plate Floor plate Sensory cells of posterior gray Sensory neurons column Anterior gray column Posterior median septum Posterior sensory root Posterior root ganglion Central canal C Anterior median fissure Sulcus limitans D Motor cells of anterior gray column Roof plate Fourth ventricle Alar plate Roof plate Median sulcus Spinal nerve Anterior motor root Choroid plexus Sensory root of vagus nerve Basal plate Vagus nerve Olivary nucleus Hypoglossal nerve Pyramid E F Figure 5-10 Stages in the development of the spinal cord (AD) and the medulla oblongata (E, F). The neural crest cells will form the first afferent sensory neurons in the posterior root ganglia of the spinal nerves and the sensory ganglia of the cranial nerves. As these fibers cross the midline, they sever the continuity between the anterior column of the gray matter of the spinal cord and the gray matter that surrounds the central canal. The fasciculus gracilis and the fasciculus cuneatus continue to ascend superiorly posterior to the central gray matter. The nucleus gracilis and the nucleus cuneatus appear as posterior extensions of the central gray matter. The substantia gelatinosa in the posterior gray column of the spinal cord becomes continuous with the inferior end of the nucleus of the spinal tract of the trigeminal nerve. The fibers of the tract of the nucleus are situated between the nucleus and the surface of the medulla oblongata. The lateral and anterior white columns of the spinal cord are easily identified in these sections, and their fiber arrangement is unchanged. Level of Decussation of Lemnisci A transverse section through the inferior half of the medulla oblongata,a short distance above the level of the decussation of the pyramids, passes through the decussation of lemnisci, the great sensory decussation. The decussation of the lemnisci takes place anterior to the central gray matter and posterior to the pyramids. It should be understood that the lemnisci have been formed from the internal arcuate fibers, which have emerged from the anterior aspects of the nucleus gracilis and nucleus cuneatus. The internal arcuate fibers first travel anteriorly and laterally around the central gray matter. They then curve medially toward the midline, where they decussate with the corresponding fibers of the opposite side. The nucleus of the spinal tract of the trigeminal nerve lies lateral to the internal arcuate fibers. The lateral and anterior spinothalamic tracts and the spinotectal tracts occupy an area lateral to the decussation of the lemnisci (Fig. They are very close to one another and collectively are known as the spinal lemniscus. The spinocerebellar, vestibulospinal, and the rubrospinal tracts are situated in the anterolateral region of the medulla oblongata. Level of the Olives A transverse section through the olives passes across the inferior part of the fourth ventricle. Internal Structure 201 Posterior median sulcus Fasciculus gracilis Nucleus gracilis Fasciculus cuneatus Nucleus cuneatus Spinal tract of trigeminal nerve Spinal nucleus of trigeminal nerve Spinal root of accessory nerve Medial longitudinal fasciculus B A Lateral corticospinal tract Posterior spinocerebellar tract Lateral spinothalamic tract Anterior spinocerebellar tract Central canal Pyramid Medial accessory olivary nucleus Decussation of pyramids Anterior median fissure A Fasciculus gracilis Central canal Nucleus gracilis Fasciculus cuneatus Nucleus cuneatus Internal arcuate fibers Spinal tract of trigeminal nerve Spinal nucleus of trigeminal nerve Spinal root of accessory nerve Inferior olivary nucleus Lateral spinothalamic tract Hypoglossal nucleus Medial longitudinal fasciculus Posterior spinocerebellar tract Anterior spinocerebellar tract Hypoglossal nerve B Decussation of medial lemnisci Pyramid Figure 5-11 Transverse sections of the medulla oblongata. Olivary Nuclear Complex the largest nucleus of this complex is the inferior olivary nucleus. The gray matter is shaped like a crumpled bag with its mouth directed medially; it is responsible for the elevation on the surface of the medulla called the olive. The cells of the inferior olivary nucleus send fibers medially across the midline to enter the cerebellum through the inferior cerebellar peduncle.
Diseases
- MPS III-B
- Cat scratch disease
- Acrorenoocular syndrome
- Disorganization syndrome
- PANDAS
- Myelodysplasia
- Kobberling Dunnigan syndrome
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