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of axes As in all cases, the properties that you can define depend on the chart type you selected You can add an additional value axis to a chart with value and category axes You can place individual data series of the chart on the second value axis This can be useful if the value ranges of two data series are very different If this is the case, you can set a different scaling factor for the secondary axis in order to balance the chart If the list of elements contains the entry ValueAxis2, the selected chart type allows you to add a secondary axis To do this, select the required value axis from the list of elements, make sure that the Visibility field is selected in order to display the axis on the chart, and finally choose the Secondary entry from the Position field (see the following illustration) This last option is very important or you will either have overlapping values on one axis or have inconsistent views of the primary information

thalamic hormones, rise for 10 to 20 min after all types of generalized seizures, including complex partial seizures, but not in absence or myoclonic types An elevation may help differentiate a hysterical seizure from a genuine one; however, serum prolactin may also be slightly elevated after a syncopal episode Detection is facilitated by collecting capillary blood from the nger on lter paper for analysis (Fisher et al) There is also a postictal rise in ACTH and serum cortisol, but these changes have a longer latency and briefer duration If changes in these hormonal levels are used as diagnostic tests, one must have information about normal baseline levels, diurnal variations, and the effects of concurrent medications Changes in body temperature, which are said to sometimes precede a seizure, may re ect hypothalamic changes but are far less consistent and dif cult to use in clinical work

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In most autopsied cases of primary generalized epilepsy of the grand mal and absence types, the CNS has been said to be grossly and microscopically normal However, it is unlikely that the brains in these cases were examined completely at least there is not a single case that has been subjected to whole-brain serial sectioning in a search for disorders of neural migration and old scars Not surprisingly, there are also no visible lesions in the seizure states complicating drug intoxication and withdrawal, transient hyperand hyponatremia, and hyper- and hypoglycemia, which presumably represent derangements at the cellular level In contrast, most of the so-called secondary epilepsies have de nable lesions These include zones of neuronal loss and gliosis (scars) or other signs of tissue loss such as a porencephaly, heterotopia, dysgenetic cortex, hamartoma, vascular malformation, and tumor The frequency of these lesions is not fully known Certainly the focal epilepsies are associated with the highest incidence of structural abnormalities, although in certain cases no morphologic change is visible In several series of cases of temporal lobe excisions, such as that of Falconer, a speci c pattern of neuronal loss with gliosis (sclerosis) in the hippocampal and amygdaloid region was found in the majority, and this abnormality is being increasingly recognized with MRI, as noted below Vascular malformations, hamartomas, and low-grade astrocytomas were less frequent; in a small number, no abnormalities could be found The widespread use of CT and MRI represents an important surrogate approach to the pathologic study of epilepsy More than 25 years ago, Gastaut and Gastaut reported that in primary grand mal and absence epilepsies, CT abnormalities were found in approximately 10 percent of cases, whereas in the Lennox-Gastaut syndrome, the West syndrome, and partial complex epilepsies it was found in 52, 77, and 63 percent, respectively Atrophy, calci cation, and malformations were the most frequent changes MRI and particularly the FLAIR images have proved to be a particularly sensitive means of detecting epileptogenic lesions of the medialbasal portion of the temporal lobes (mesial temporal sclerosis; Fig 16-2) Repeatedly, patients are observed in whom MRI disclosed a cortical or subcortical developmental malformation such as a cortical heterotopia or another surgically treatable lesion of the temporal lobe, even after CT scanning had failed to do so More subtle epileptogenic foci may be demonstrated by positron emission tomography (PET) or by interictal single-photon emission computed tomography (SPECT) Ictal SPECT, which shows hyperperfusion of the seizure focus, is a more demanding but also more sensitive and speci c procedure.

Figure 45-5 The shaded area represents the zone of the action potential, which is negative to all other points on the ber surface It is shown at three points in its course (from left to right) along the ber At each point, the correspondingly lettered portion of the triphasic muscle action potential displayed on the display screen re ects the potential difference between the active (vertical arrow) and reference (Ref) electrodes Polarity in this and subsequent gures is negative upward as depicted The time calibration is on the screen

Again, as you can see, this is configured in the Chart Designer setting Refine rather than in the wizard step-by-step process The process of using the steps within the wizard approach will be displayed in an example later in this chapter

becomes relatively positive again (at C) It then returns to its resting isopotential position The net result is a triphasic action potential, as in Fig 45-5 This con guration is typical of the ring of a single ber The electrical activity of various muscles is recorded both at rest and during active contraction by the patient As indicated earlier, muscle bers do not normally discharge until activated together in motor unit activity This involves the almost simultaneous contraction of all the muscle bers innervated by a single anterior horn cell Although the typical con guration of a motor unit potential (MUP) is triphasic, up to 10 percent of normal MUPs consist

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