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found for aneurysms between 7 and 10 mm, and a risk ranging from 06 to 35 percent for lesions between 13 and 24 mm (depending on location) The risk ranged up to 10 percent for aneurysms greater than 25 mm diameter The yearly rates for rupture were higher in all categories if there had been prior bleeding from another site The location of the lesion also had great bearing on the risk of rupture, as did increasing age; notably, vertebrobasilar and posterior cerebral aneurysms bled at a rate many times higher than the others The importance of such data is underscored by the comparison to the risk of surgery and endovascular treatment, which begin to exceed the risk of bleeding within 5 years in the smaller aneurysms located in the carotid circulation Giant Aneurysms As has been stated, these are believed to be congenital anomalies even when there is considerable atherosclerosis in their walls They may become enormous in size, by de nition greater than 25 cm in diameter, but sometimes twice or more as large Most are located on a carotid, basilar, anterior, or middle cerebral artery They grow slowly by accretion of blood clot within their lumens or by the organization of surface blood clots from small leaks At a certain point they may compress adjacent structures, eg, those in the cavernous sinus, optic nerve, or lower cranial nerves The giant fusiform aneurysm of the midbasilar artery, with signs of brainstem ischemia and lower cranial nerve palsies, is a relatively common form Clotting within the aneurysm may cause ischemic infarction in its territory of supply Giant aneurysms may rupture and cause subarachnoid hemorrhage, but not nearly as often as saccular aneurysms This clinical observation has been con rmed by the International Study, referred to above Treatment is surgical if the lesion is symptomatic and it is accessible; treatment is with endovascular techniques if the lesion is in the vertebral or midbasilar artery Obliteration of the lumen, coupled with vascular bypass procedures, has been successful in the hands of a few cerebrovascular neurosurgeons, but the morbidity is high Some aneurysms can be ligated at their necks, others by trapping or by the use of an intravascular detachable balloon Drake has summarized his experience in the treatment of 174 such cases Ojemann and colleagues have also had singular success in treating these lesions by a combination of surgical techniques; in more than 40 cases, half of them trapped and half obliterated, there was not a single fatality Some have been wrapped in muslin or similar material with mixed results We have followed one such patient operated by T Sundt over 25 years ago Recent attempts at stabilizing the expansion of the aneurysm by stenting are under study.

Precerebellar nucleus cell (spinocerebellar pathways, brainstem reticular nuclei, pontine nuclei, etc) Inferior olivary nucleus cell Descending motor systems

The number one convention of risk management is diversi cation The purpose of diversi cation is to spread the risk across a range of components so that if one component suffers a loss, the balance of the components in a well-diversi ed portfolio will absorb and make up for the loss The problem with diversi cation as a sole risk management strategy is the lack of protection from systemic risk No matter how diversi ed the portfolio, when the bulk of equities on the planet go down, the portfolio will go down This is not unusual, nor does it mean that something is wrong with diversi cation It is just a fact As we discussed earlier, investors are often taken aback by the effect of negative economics on their portfolio This is because so much emphasis has been placed on diversi cation that investors are unprepared to manage systemic portfolio risk This often includes large portfolio managers as they struggle to maintain the balance between aggressive returns and managing risk There is no silver bullet for risk management; it is a problem with a many-faceted solution Let s look at the types of risk and identify the shortcomings of risk management strategies When managing systemic risk, you have several tools available Certainly diversi cation is the primary tool, but the downside to diversi cation is a loss of individual component or sector performance If you are diversi ed into 30 different stocks such as the Dow Industrials stocks, a strong performance in one stock may be offset by a negative performance in another, or at least growth will be checked by any poorly performing components The S&P 500, QQQ, and Russell 2000 are well diversi ed on their own These broad indices generate year-on-year returns and

Figure 5-5 The physiologic organization of cerebellar circuitry The main output of the deep cerebellar nuclei is excitatory and is transmitted through mossy and climbing bers This main loop is modulated by an inhibitory cortical loop, which is effected by Purkinje cell output but indirectly includes the other main cell types through their connections with Purkinje cells Recurrent pathways between the deep nuclei and cortical cells via mossy and climbing bers complete the cerebellar servomechanism for motor control (Reproduced with permission from Kandel ER, Schwartz JH, Jessel TM: Principles of Neural Science, 4th ed New York: McGrawHill, 2000)

The disturbances of movement and posture that result from lesions of the human cerebellum were rst cogently analyzed by two eminent neurologists, Joseph Babinski and Gordon Holmes For Ba-

The final group, the class 5 chart types, comprises the delta chart and its variant waterfall chart These chart types use the flowing concept to display information You probably have seen or worked with this type of chart when the goal is to group together multiple sets of information, normally to offer some sort of range of information and display it graphically

binski, the essential function of the cerebellum was the orchestration of muscle synergies in the performance of voluntary movement A loss or impairment of this function ie, asynergia or dyssynergia resulted in irregularity or fragmentation of the normal motor sequences involved in any given act This de cit, most apparent in the execution of rapidly alternating movements, was referred to by Babinski as dys- or adiadochokinesis, as discussed below in the description of incoordination He also pointed out that this was accompanied by certain maladjustments of stance and by catalepsy (perseveration of a posture), features that are not as widely appreciated by modern observations The abnormalities observed by Holmes were characterized as being in the acceleration and deceleration of movement He summarized them as defects in the rate, range, and force of movement, resulting in an undershooting or overshooting of the target He used the term decomposition of movements to describe the fragmentation of a smooth movement into a series of irregular, jerky components In Holmes s view, probably incorrectly, these abnormalities were attributable to an underlying hypotonia The terminal ( intention ) tremor, for example, and the inability to check the displacement of an outstretched limb were attributed to this latter defect (see further on)

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