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occur above the plane of the tentorium With acute masses, a 3- to 5-mm horizontal displacement of the pineal calci cation is associated with drowsiness; 5 to 8 mm, with stupor; and greater than 8 or 9 mm, with coma (Ropper, 1986) Although in some cases the downward shift predominates and in others it is horizontal, on MRI the latter is usually disproportionate to vertical displacement, and the clinical state corresponds more closely to the degree of lateral shift Possibly, the con guration differs entirely between cases, such as the one reported by Pleasure and colleagues, in which a syndrome of low CSF pressure caused purely downward herniation and stupor that could be corrected by the infusion of uid into the spinal canal Others, notably Reich and colleagues, nd the evidence for vertical shift to be more compelling than for horizontal displacement The location as well as the size of a mass determines the degree of brain distortion and displacement of crucial structures in the lower diencephalon and upper midbrain Andrews and colleagues have pointed out that frontal and occipital hemorrhages are less likely to displace deep structures and to cause coma than are clots of equivalent size in the parietal or temporal lobes Nor is it surprising that slowly enlarging masses, such as brain tumors, may sometimes cause massive shifts of brain tissue yet result in few clinical changes In other words, all of the above comments pertain only to structural changes that are acute

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an erratic con guration and starting and stopping abruptly They are seen in some myopathies, in hypothyroidism, and in certain denervating disorders and are a mark of chronicity (lesions over 6 months old) High-frequency coupling of action potentials into doublets, triplets, or higher multiples of single units, indicating instability in repolarization of the nerve ber to a muscle, occurs in tetany and in the early stages of myokymia The cramp-like contracture of McArdle disease and phosphofructokinase de ciency is associated with electrical silence of contracting muscle This feature is an important part of the de nition of true physiologic muscle contracture (as distinguished from chronic shortening of a muscle and its tendon which, strictly speaking, is a pseudocontracture) Abnormalities in Amplitude, Duration, and Shape of Motor Unit Potentials Figures 45-9 (schematically) and 45-10 depict the ways in which disease processes affect the motor unit and the appearance of the MUP in the EMG Motor Unit Potentials in Denervation Early in the course of denervation, many motor units with functional connections to the spinal cord are unaffected, and though the number of MUPs appearing during contraction is reduced, the con gurations of the remaining ones are quite normal In time, the remaining MUPs often increase in size and in electrical amplitude, perhaps two to three times normal, and become longer in duration and sometimes polyphasic (more than four phases) Such large and sometimes giant potentials (see Figs 45-9C and 45-10B) are believed to arise from motor units containing more than the usual number of muscle bers that are spread out over a greatly enlarged territory within the muscle Presumably, new nerve twigs have sprouted from nodal points and terminals of undamaged axons and have reinnervated previously denervated muscle bers, thus adding them to their own motor units Soon after reinnervation, the MUPs generated will be low in amplitude, extremely prolonged, and polyphasic, ndings that constitute a transitional con guration of early reinnervation These amplitudes disappear as the motor unit is reestablished Increased amplitude is usually associated with very chronic, proximal axon loss, eg, with remote poliomyelitis and chronic cervical radiculopathy These MUPs are to be differentiated from (1) polyphasic potentials of.

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Figure 45-9 The shaded muscle bers are functional members of one motor unit, whose axon enters from the upper left and branches terminally to innervate the appropriate muscle bers The action potential produced by each motor unit is seen in the upper right: its duration is measured between the two vertical lines The normal-appearing but unshaded bers belong to other motor units A Hypothetical situation, with ve muscle bers in the active unit B In this myopathic unit, only two bers remain active; the other three (shrunken) have been affected by one of the primary muscle diseases C Four bers which originally belonged to other motor units and had been denervated have now been reinnervated by terminal sprouting from an undamaged axon Both the motor unit and its action potential are now larger than normal Note that only under these abnormal circumstances do bers in the same unit lie next to one another

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observed in some cases of Eulenberg paramyotonia, Nielsen and colleagues have found a decreasing recruitment pattern and increasing activity after each of a succession of voluntary contractions This is the converse of what happens in congenital myotonia (Thompsen disease) As shown by the single- ber EMG studies of Denny-Brown and Nevin, myotonia is generated by single muscle bers, and the mechanism of the membrane instability, at least in some forms, seems to involve changes in the chloride conductance These disorders are discussed in subsequent chapters In the stiff-man syndrome, painful muscle spasms and stiffness are generated by a spinal mechanism; the EMG potentials resemble normal motor units but are abnormal by virtue of continuous ring at rest (see page 1279) Complex repetitive discharges formerly referred to as bizarre high-frequency discharges and, even earlier, as pseudomyotonia consist of repetitive spontaneous potentials often having

Figure 45-10 Single voluntary motor unit potentials A Normal B Prolonged polyphasic potential seen with reinnervation C Giant unit normally shaped but of much greater amplitude than normal D Brief, lowamplitude myopathic units Calibrations: 5 ms (horizontal) and 1 mV in A and B; 5 mV in C; 100 mV in D (vertical)

Coma is always a symptomatic expression of an underlying disease Sometimes the primary disorder is perfectly obvious, as with severe cranial trauma All too often, however, the patient is brought to the hospital in a state of coma and little pertinent medical in-

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