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of the superior cerebellar peduncle, following their decussation, de- Thalamacortical fibers scend in the ventromedial tegmentum of the brainstem via the central Thalamus tegmental fasciculus and terminate Lateral Dentatorubral in the reticulotegmental and paraventral tract nucleus median reticular nuclei of the pons and inferior olivary nuclei of the Red medulla These nuclei, in turn, projDentotothalamic nucleus tract ect via the inferior cerebellar peduncle to the cerebellum, mainly the anterior lobe, thus completing a Superior cerebellar-reticular-cerebellar feedcerebellar peduncle back system (Fig 5-3) Globose Cerebellar Decussation The fastigial nucleus sends emboliform nuclei of brachium conjunctivum bers to the vestibular nuclei of both Descending sides and, to a lesser extent, to other division nuclei of the reticular formation of of peduncle the pons and medulla There are Dentate nucleus also direct ber connections with middle Cerebellar the alpha and gamma motor neupeduncles rons of the spinal cord The inferior inferior olivary nuclei project via the restiform body (inferior cerebellar peReticulotegmental nucleus duncle) to the contralateral cerebelFeedback Paramedian reticular nucleus lar cortex and corresponding parts (of medulla) of the deep cerebellar nuclei Thus thecerebellum in uences motor acFeedback tivity through its connections with the motor cortex and brainstem nuclei and their descending motor pathways The integration at the thalamic level of basal ganglionic in uences with those of the cereFigure 5-3 Dentatothalamic and dentatorubrothalamic projections via the superior cerebellar peduncle The bellum is detailed in Chap 4 Clinicopathologic observa- feedback circuit via the reticular nuclei and reticulocerebellar bers is also shown (Mollaret triangle) tions indicate that the cerebellar the dentate nucleus to the ventrolateral thalamus and motor cortex cortex, and the anterior lobe in particular, is organized somatotopThe dentatal neurons were shown to re just before the onset of ically This view has been amply con rmed experimentally by the volitional movements, and inactivation of the dentatal neurons demapping of evoked potentials from the cerebellar cortex, elicited layed the initiation of such movements The interpositus nucleus by a variety of sensory stimuli, and an analysis of the motor effects also receives cerebrocortical projections via the pontocerebellar produced by stimulation of speci c parts of the cerebellar cortex system; in addition, it receives spinocerebellar projections via the The topographic sensory representation of body parts based on intermediate zone of the cerebellar cortex The latter projections these experimental observations is assumed to be similar to the convey information from Golgi tendon organs, muscle spindles, motor map but is probably not as distinct The similarity between cutaneous afferents, and spinal cord interneurons involved in this scheme and the one derived from the study of human disease movement The interpositus nucleus res in relation to a movement becomes apparent when one considers the results of cerebellar leonce it has started Also, the prepositus nucleus appears to be resions discussed further on Diffuse degenerations of the cerebellum, sponsible for making volitional oscillations (alternating moveof course, have widespread effects, including motor, articulatory, ments) Its cells re in tandem with these actions, and their regugait and eye movements larity and amplitude are impaired when these cells are inactivated In addition, Thach has pointed out that the nucleus interpositus Role of the Deep Cerebellar Nuclei The physiologic studies of normally damps physiologic tremor; he has suggested that this may Allen and Tsukahara and those of Thach and colleagues have play a part in the genesis of so-called intention tremor described greatly increased our knowledge of the role of the deep cerebellar further on The fastigial nucleus controls antigravity and other musnuclei These investigators studied the effects of cooling the deep cle synergies in standing and walking; ablation of this nucleus nuclei during a projected movement in the awake macaque mongreatly impairs these motor activities key Their observations, coupled with established anatomic data, permit the following conclusions The dentate nucleus receives inNeuronal Organization of the Cerebellar Cortex Coordinated formation from the premotor and supplementary motor cortices via and uid movements result from a neuronal organization in the the pontocerebellar system and helps to initiate volitional movecerebellum, which permits a computational comparison between ments The latter are accomplished via efferent projections from.

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Although the abruptness with which the stroke develops and the lack of prodromal symptoms point strongly to embolism, the diagnosis is based on the total clinical picture As already emphasized, the presence of atrial brillation, a history of myocardial infarction (recent or in the preceding months), cardiac valvular disease or a prosthetic valve, or the occurrence of embolism to other vascular territories of the brain or to other regions of the body all support the diagnosis of embolism This diagnosis always merits careful consideration in young persons, in whom atherosclerosis is unlikely In instances in which the cause of embolisms cannot be ascertained, the practice is nevertheless to class them as thromboembolic Laboratory Findings Not infrequently the rst sign of myocardial infarction is the occurrence of cerebral embolism; therefore it is advisable that an ECG and echocardiogram be obtained in all patients with stroke of uncertain origin, particularly since about 20 percent of myocardial infarctions are of the silent variety; if the ECG does not yield relevant information, prolonged study of heart rhythm with Holter monitoring should be undertaken Also, as indicated earlier, it is advisable in the elderly or in patients with severe atherosclerosis to image the aortic arch with ultrasound or MRA, looking for plaques greater than 4 mm in thickness (Amarenco et al) Transesophageal echocardiography, which has a higher sensitivity than transthoracic echocardiography, is an important test in the evaluation of stroke in younger patients, in whom a PFO may be a mechanism for paradoxical embolism, and in older patients with arteriopathy, in whom an atrial clot or an aortic plaque may be responsible In a study of 824 patients at the Cleveland Clinic (Leung and associates), transesophageal echocardiography detected a potential source of embolism in 50 percent, an atrial clot in 7 percent, and a complex aortic atheroma in 13 percent of those with normal transthoracic studies The precise indications for this test, however, have not been clearly determined, and various studies give widely varying estimates of its usefulness in detecting a cardiac thrombus In some 30 percent of cases, cerebral embolism produces a hemorrhagic infarct CT scanning or MRI may be helpful in showing the more intense hemorrhagic infarcts, particularly if the scan is repeated on the second or third day or later Only in a minority of these instances do red cells enter the CSF rarely as many as 10,000/mm3 In the milder cases of hemorrhagic infarction, a slight xanthochromia may appear after a few days Septic embolism resulting from subacute bacterial endocarditis may cause the white blood cells (WBCs) in the CSF to be increased, up to 200/mm3 but occasionally much higher; the proportion of lymphocytes and polymorphonuclear cells varies with the acuteness of the in ammatory reaction There may also be an equal number of red blood cells and a faint xanthochromia The protein content is elevated but the glucose content is normal However, no bacteria are seen or obtained by culture By contrast, the CSF formula in septic embolism from acute bacterial endocarditis may be that of a purulent meningitis Course and Prognosis The remarks concerning the immediate prognosis of atherothrombotic infarction apply to embolic infarction as well Most patients survive the initial insult, and in many the neurologic de cit may recede relatively rapidly, as indicated above Progressive brain swelling occurs in a small proportion, less than 5 percent, and mainly in patients with embolic occlusion of.

Step 1 of 2 of the wizard is shown in the following illustration Only a few options are available, as defined in Table 2-1

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