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of four or more phases (polyphasic potentials); an excess of polyphasic potentials beyond this is pathologic Normal muscle in the resting state should be electrically silent; the small tension spoken of as muscle tone has no EMG equivalent There are, however, two closely related types of normal spontaneous activity and another that is induced by the insertion of the needle itself One is a low-amplitude, 10- to 20-mV monophasic (negative) potential of very brief (05 to 1 ms) duration These represent single or synchronized MEPPs due to the small number of ACh quanta that are being released all the time They are normally sparse but are most evident when the recording needle electrode is placed near a motor end plate ( end-plate noise ) Fortuitous placement of the needle electrode very close to or in contact with the end plate gives rise to a second type of normal spontaneous activity That is characterized by irregularly discharging highfrequency (50- to 100-Hz) biphasic spike discharges, 100 to 300 mV in amplitude (ie, large enough to cause an isolated muscle action potential) These potentials have been termed end-plate spikes and represent discharges of single muscle bers excited by spontaneous activity in nerve terminals They must be distinguished from brillation potentials (see later) Finally, insertion of the needle electrode into the muscle injures and mechanically stimulates many bers, causing a burst of potentials of short duration (300 ms) This is referred to as normal insertional activity When muscle is voluntarily contracted, the action potentials of motor units begin to appear One can observe a pattern of force build up by watching the progressive recruitment of MUPs; the initial ones, representing smaller motor units, ring at rates of 5 to 10 per second With increased force of contraction, there is recruitment of larger, previously inactive motor units as well as an increased rate of ring (40 to 50 per second; Fig 45-6A) Since individual MUPs can no longer be distinguished during maximal voluntary contraction, this activity is referred to as a complete interference pattern (Fig 45-6A, right) This is seen not only as a summated signal pattern but is also heard as a mixed highfrequency clicking when the electrical activity is made audible As muscles relax, more and more units drop out If a muscle is weakened by denervation or if electrical conduction is blocked, there will obviously be fewer MUPs, but the ring rate is still rapid (reduced recruitment, see Fig 456B) In contrast, with poor voluntary effort and with upper motor neuron lesions, the MUPs re in decreased numbers, at slower rates, and often in an irregular pattern (termed poor activation) In the usual EMG examination, a plan for the study is made based on detailed knowledge of muscular innervation and focusing on the regions affected by weakness In some patients, as in those with motor neuron diseases or polymyositis, a wider sampling of muscles is required to detect changes in asymptomatic regions The Abnormal Electromyogram Clinically important deviations from the normal EMG include (1) increased or decreased activity upon insertion of the needle; (2) the occurrence of abnormal spontaneous activity during the relaxed state ( brillation potentials, positive sharp waves, fasciculation potentials, cramp potentials, myotonic discharges, myokymic potentials); (3) abnormalities in the amplitude, duration, and shape.

Figure 45-6 Patterns of motor unit recruitment A Normal With each increment of voluntary effort, more and larger units are brought into play until, with full effort at the extreme right, a complete interference pattern is seen in which single units are no longer recognizable B After denervation, only a single motor unit is recorded despite maximal effort It is seen to re repetitively C With myopathic diseases, a normal number of units is recruited on minimal effort, though the amplitude of the pattern is reduced Calibrations: 50 ms (horizontal) and 1 mV in A and B; 200 mV in C (vertical)

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MRI is the most important diagnostic tool for the detection of structural abnormalities underlying epilepsy Medial temporal sclerosis, glial scars, porencephaly, heterotopias, and other disorders of neuronal migration can be clearly visualized After a seizure, particularly one with a focal component, MRI sometimes discloses subtle focal cortical swelling and signal change in the FLAIR sequence, or, if a contrast agent is administered, an ill-de ned cortical blush may be visible on CT or MRI There is a rough relationship between the duration of seizure activity and the intensity and size of these cortical changes Likewise, angiography performed soon after a seizure may show a focal area of enhanced ow This phenomenon was often a source of confusion when radionuclide scans were routinely performed for the evaluation of new seizures focal increased uptake being mistaken for a tumor or stroke All of these imaging abnormalities are thought to re ect transient disruption of the blood-brain barrier, and they rarely persist for more than a day or two Less well understood is the nding on MRI of increased T2 signal (probably due to hypoxia) in the hippocampi after a prolonged seizure or status epilepticus The CSF occasionally contains a small number of white blood cells (rarely up to 50/mm3, but more often in the range of 10/mm3) in about 15 percent of patients after a seizure A slight increase in protein is also possible Like the imaging abnormalities these ndings may lead to spurious conclusions about the presence of an intracranial infection, particularly if polymorphonuclear leukocytes predominate Nonetheless, a signi cant pleocytosis after a seizure should always be construed as a sign of in ammatory or infectious disease Systemic acidosis is a common result of convulsive seizures, and it is not unusual for the serum pH to reach levels near or below 7 if taken immediately after a convulsion Of more practical value is the fact that almost all generalized convulsions produce a rise in serum creatine kinase activity that persists for hours, a nding that could be used to greater advantage in emergency departments to assist in distinguishing seizures from fainting Of course, extensive muscle injury from a fall or prolonged compression during a period of unconsciousness can produce the same abnormality Concentrations of serum prolactin, like those of other hypo-.

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The put side breakeven is reached by subtracting the total captured premium from the strike price: 5750 984 4766