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than for PFO) This mechanism comes into play mainly in considering the causes of stroke in the younger patient Subendocardial broelastosis, idiopathic myocardial hypertrophy, cardiac myxomas, and cardiac lesions of trichinosis are rare causes of embolism The vegetations of acute and subacute bacterial endocarditis give rise to several different lesions in the brain (page 606) Mycotic aneurysm is a rare complication of septic embolism and may be a source of intracerebral or subarachnoid hemorrhage Marantic or nonbacterial thrombotic endocarditis is a frequently overlooked cause of cerebral embolism; at times it produces a baf ing clinical picture, especially when associated, as it often is, with carcinomatosis, cachexia from any cause, or lupus erythematosus This subject is discussed on page 735 Mitral valve prolapse may be a source of emboli, especially in young patients, but its importance has probably been overestimated The initial impetus for considering this abnormality as a source of embolus came from the study of Barnett and colleagues of a group of 60 patients who had TIAs or partial strokes and were under 45 years of age; prolapse was detected (by echocardiography and a characteristic midsystolic click) in 24 patients but in only 5 of 60 age-matched controls However, in several subsequent large studies (Sandok and Giuliani and Jones et al), only a very small proportion of strokes in young patients could be attributed to prolapse; even then, the connection was only inferred by the exclusion of other causes of stroke Indeed, in a recent study using stringent criteria for the echocardiographic diagnosis of prolapse, Gilon and colleagues could not establish any relation to stroke Rice and colleagues have described a family with premature stroke in association with valve prolapse and a similar relationship has been reported in twins; the same may occur in Ehlers-Danlos disease The pulmonary veins are a potential if infrequent source of cerebral emboli, as indicated by the occurrence of cerebral abscesses in association with pulmonary suppurative disease and by the high incidence of cerebral deposits secondary to pulmonary carcinoma In Osler-Weber-Rendu disease, pulmonary shunts serve as a conduit for emboli As remarked above, surgery of the neck and thorax can be complicated by cerebral embolism A rare type is that which follows thyroidectomy, where thrombosis in the stump of the superior thyroid artery extends proximally until a section of the clot, protruding into the lumen of the carotid, is carried into the cerebral arteries During cerebral arteriography, emboli may arise from the tip of the catheter, or manipulation of the catheter may dislodge atheromatous material from the aorta or carotid or vertebral arteries and account for some of the accidents during this procedure Transcranial Doppler insonation has suggested that small emboli frequently arise during these procedures; a study by Bendszus and colleagues found that 23 of 100 consecutive patients had new cortical lesions shown on diffusion-weighted MRI just after cerebral arteriography However, none of these were symptomatic and with good technique, emboli from vascular catheters are infrequent Cerebral embolism must always have occurred when secondary tumor is deposited in the brain, and cerebral embolism regularly accompanies septicemia, but a mass of tumor cells or bacteria is seldom large enough to occlude a cerebral artery and produce the picture of stroke Nevertheless, tumor embolism with stroke has been reported from cardiac myxomas and occasionally with other tumors It must be distinguished from embolism due to marantic endocarditis that complicates malignant neoplasms (nonbacterial thrombotic endocarditis, discussed further on) Cerebral fat embolism is related to severe bone trauma As a rule, the emboli are.

tarinen et al have suggested that a search be made for these antibodies in patients with polyneuropathies of obscure origin It is not clear how many of their cases could be attributed to nutritional de ciency We have not encountered a de nite case despite systematic attempts to detect the special antibodies in the evaluation of obscure neuropathies Numerous other systemic diseases have reportedly been conjoined with peripheral neuropathy, among them, temporal arteritis In most of these anecdotal reports it is impossible to interpret etiologic relationships

point can be used by assigning the BI portal to another company portal or a federated portal Keep in mind that the purpose of this chapter is to introduce the BEx Web Analyzer reporting functionality and navigation in general, not to review each of the different options in detail Individual options will be covered in more depth throughout the course of this book

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These are among the most clinically complex diseases of the peripheral nerves Involvement of multiple spinal nerve roots produces a distinctive but sometimes confusing constellation of ndings, usually quite different from those of polyneuropathy and from multiple mononeuropathies As described earlier, muscle weakness due to polyradiculopathy is characteristically asymmetrical and variably distributed in proximal and distal parts of the limbs, re ecting the fact that the involved muscles have a common root innervation (for example, the combination of hamstring and gastrocnemius, or of iliopsoas, quadriceps, and obturator) However, muscles with similar innervation are not necessarily affected to the same degree because of the disproportionate contribution of a given root to each muscle it supplies Sensory loss tends also to be similarly patchy and to involve both the proximal and distal aspects of a dermatome As a rule, pain is common (though not invariable) while the sensory ndings tend to be less prominent than the motor ones In keeping with nerve root pattern, certain tendon re exes may be spared; a normal ankle jerk combined with an absent knee jerk, or the opposite, are particularly suggestive of a polyradiculopathy (or a lumbar plexopathy) Pain often takes the form of sharp jabs projected into the innervated zone of the involved root As with mononeuritis multiplex, the cumulative effect of multiple root lesions can simulate a polyneuropathy in which case the tendency for polyradiculopathy to involve proximal muscles is the most helpful distinguishing feature A special pattern of polyradiculopathy may occur wherein all the sensory roots are involved diffusely The clinical state is similar to that of a sensory ganglionopathy described earlier Large- and small- ber sensory loss is combined with ataxia while power is normal and there is no atrophy A prominent feature is shooting and burning pain We have also occasionally found sensory loss over the anterior abdomen and thorax, a nding more typical of chronic dying-back axonal polyneuropathy Some of the diseases that affect nerve roots solely or predominantly have already been discussed They can be grouped into three broad categories: (1) diseases of the spinal column that compress adjacent roots; (2) in ltrative diseases of the meninges that secondarily involve the roots as they course through the subarachnoid space, including neoplastic granulomatous in ltration; and (3) intrinsic neuropathies, usually in ammatory, infectious, or diabetic, that have a predilection for the radicular portion of the nerves An elevated CSF protein and a pleocytosis usually accompany neoplastic or in ammatory meningeal diseases; the others show variable formulas in the spinal uid Often what appears to be a polyneuropathy on clinical grounds turns out to have an electrophysiologic pattern of root disease at multiple spinal levels McGonagle and colleagues estimated that.

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