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caused by infarction or tumor in the ipsilateral cerebellar hemisphere or by demyelinating disease affecting cerebellar connections in the brainstem The ataxia of severe sensory neuropathy and of posterior column disease of the spinal ( sensory ataxia ) cord may simulate cerebellar ataxia; presumably this is due to involvement of the large peripheral spinocerebellar afferent bers However, there should seldom be dif culty in separating the two if one takes note of the loss of distal joint position sense, absence of associated cerebellar signs such as dysarthria or nystagmus, loss of tendon re exes, and the corrective effects of vision on sensory ataxia In peripheral neuropathy of this nature and in spinal cord disease, the Romberg sign is invariably present, re ecting a parallel dysfunction of large afferent bers in the posterior columns; this sign is not found in lesions of the cerebellar hemispheres except that the patient may initially sway with eyes open and a bit more with eyes closed This type of tremor reaches an extreme form in the large- ber polyneuropathy related to antibodies against myelin-associated glycoprotein (MAG) but the features are closer to an exaggerated essential tremor, as discussed in the next chapter and in Chap 46 In the Miller Fisher syndrome, which is considered to be a variant of Guillain-Barre neuropathy, sensation is intact or affected only slightly and the severe ataxia and intention tremor are presumably

due to a highly selective peripheral disorder of spinocerebellar nerve bers Affection of these same bers in the spinocerebellar tracts of the cord may produce the same effects; subacute compressive lesions such as thoracic meningioma or demyelinating lesions are the usual causes Again, there is a prominent Romberg sign Occassionally, a cerebellar-like tremor in one limb results from a lesion in the dorsolateral cord that interrupts afferent bers, presumably those directed to the spinocerebellar tracts Vertiginous ataxia is primarily an ataxia of gait and is distinguished by the obvious complaint of vertigo and listing to one side, past-pointing, and rotary nystagmus (Chap 15) The nonvertiginous ataxia of gait due to vestibular paresis (eg, streptomycin toxicity) has special qualities described in Chap 7 Vertigo and cerebellar ataxia may be concurrent, as in some patients with a paraneoplastic disease and in those with infarction of the lateral medulla and inferior cerebellum An unusual and transient ataxia of the contralateral limbs occurs acutely after infarction or hemorrhage in the anterior thalamus (thalamic ataxia); in addition to neighborhood signs, there is often an accompanying unilateral asterixis Also, a lesion of the superior parietal lobule (areas 5 and 7 of Brodmann) may rarely result in a similar ataxia of the contralateral limbs

The physician rst called on to attend a patient who has had a closed (blunt) head injury will generally nd the patient in one of three clinical conditions, each of which must be dealt with differently Usually it is possible to categorize the patient by assessing his mental and neurologic status when rst seen and at intervals after the accident In many emergency wards and intensive care units, the Glasgow Coma Scale is used as a rapid reference to accomplish this purpose (Table 35-1) It registers three aspects of neurologic function: eye opening, verbal response, and motor response to various stimuli The scores provided by this scale have been found to correspond roughly with outcome of the head injury, as discussed further on The scale uses a summed score with a maximum of 15; a score of 7 or less is considered to re ect severe trauma and a poor clinical state, 8 to 12, moderate injury, and higher scores, mild injury

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Patients Who Are Conscious or Are Rapidly Regaining Consciousness (Minor Head Injury)

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This is the most frequently encountered clinical situation Roughly, two degrees of disturbed function can be recognized within this category In one, the patient was not unconscious at all but only stunned momentarily or saw stars This injury is insigni cant when judged in terms of life or death and brain damage though, as we point out further on, there is always the possibility of a skull fracture or the later development of an epidural or subdural hematoma Moreover, the patient is still liable to a troublesome post-

Figure 35-6 CT scan without contrast infusion showing areas of hemorrhagic contusion adjacent to bony prominences There is also slight subarachnoid blood along the tentorium and in the insular cisterns, both typical of traumatic bleeding

Figure 35-7 CT scan (left) and MRI (right) from a patient with diffuse axonal injury There are multiple small hemorrhagic areas (one of which is shown by the dark arrow) in the cerebral white matter The MRI highlights the small amount of blood in these lesions Also shown are a contusion in the anterior temporal lobe (white arrow), which often accompanies the deep type of axonal injury, and blood in the ventricle

filtering their information If required additional buttons can be available after the initial drilldown from the current button grouping So, what could happen is that after the business user has drilled down to the Customer Level there can be a list of buttons to allow even further drilldown by the customer at that point Notice that a number of Web items have been used for this display, and the format has been developed around the sizing of the information and the functionality

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