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is the not entirely correct notion articulated by Damasio and Geschwind, that Wernicke s and Broca s areas are spared, and the critical structure involved is the arcuate fasciculus This ber tract streams out of the temporal lobe, proceeding somewhat posteriorly, around the posterior end of the sylvian ssure; there it joins the superior longitudinal fasciculus, deep in the anteroinferior parietal region, and proceeds forward, deep to the suprasylvian operculum, to the motor association cortex, including the Broca s and Exner s areas (see Fig 22-7) However, in most of the reported cases, including those described by the Damasios, the left auditory complex, insula, and supramarginal gyrus were also involved In any case, the usual cause of conduction aphasia is an embolic occlusion of the ascending parietal or posterior temporal branch of the middle cerebral artery, but other forms of vascular disease, neoplasm, or trauma in this region may produce the same syndrome The concept of conduction aphasia, as outlined above, remains a useful theoretic construct, although not all authors are in agreement as to its purity as an aphasic syndrome Mohr, in his analysis of the writings on this subject, found that the distinction between conduction aphasia and Wernicke s aphasia, mainly one of degree of auditory comprehension, was ambiguous clinically and that the underlying lesions in the two syndromes were much the same A summary of the arguments against a subcortical disconnection and those favoring a cortical origin can be found in the report of the condition with focal seizures by Anderson and colleagues Pure Word-Deafness This uncommon disorder, originally described by Lichtheim in 1885, is characterized by an impairment of auditory comprehension and repetition and an inability to write to dictation Self-initiated utterances are usually correctly phrased but sometimes paraphasic; spontaneous writing and the ability to comprehend written language are preserved, thus distinguishing this disorder from classic Wernicke s aphasia Patients with pure word-deafness may declare that they cannot hear, but shouting does not help, sometimes to their surprise Audiometric testing and auditory evoked potentials disclose no hearing defect, and nonverbal sounds, such as a doorbell, can be heard without dif culty The patient is forced to depend heavily on visual cues and frequently uses them well enough to understand most of what is said However, tests that prevent the use of visual cues readily uncover the de cit If able to describe the auditory experience, the patient says that words sound like a jumble of noises As in the case of visual verbal agnosia (see below), the syndrome of pure auditory verbal agnosia is not pure, particularly at its onset, and paraphasic and other elements of Wernicke s aphasia may be detected (Buchman et al) At times this syndrome is the result of resolution of a more typical Wernicke s aphasia, and it will be recognized that worddeafness is an integral feature of all instances of Wernicke s aphasia Conceptually it has been thought of as an exclusive injury of the auditory processing system In most recorded autopsy studies, the lesions have been bilateral, in the middle third of the superior temporal gyri, in a position to interrupt the connections between the primary auditory cortex in the transverse gyri of Heschl and the association areas of the superoposterior cortex of the temporal lobe In a few cases unilateral lesions have been localized in this part of the dominant temporal lobe (see page 397) Requirements of small size and super ciality of the lesion in the cortex and subcortical white matter are best ful lled by an embolic occlusion of a small branch of the lower division of the middle cerebral artery.

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One of the most common mistakes in dashboard development is to attempt to squeeze as much into the screen as possible If we try to fit too much into one screen, it ceases to be a dashboard and becomes a visual bulletin board If this is the result then what you have is someone that has to understand the navigational approach to reading the dashboard rather than analyzing the dashboard So what we start to see is someone trying to expand the dashboard the correct way to see what they need and then start to focus on this specific issue such as looking at bullets, detailed data, and anything else we ve decided to add to our dashboard over time rather than the true needs for our MBOs The following illustration is an example of this effect The actual metrics and the approach to displaying those metrics are good, but the developer started to add in hyperlinks at the bottom of the page, a To Do list or Action List, additional scroll bars since we couldn t get everything on the one screen, adding additional colors to highlight whatever is critical since everything is starting to get so tight that we really can t distinguish what is a KPI versus what is just information At some point during the development we lost track of what the actual KPIs are that we initially used the dashboard to understand

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at all This comes about because these muscles are bilaterally innervated; ie, stimulation of either the right or left motor cortex results in contraction of these muscles on both sides of the body Upper motor neuron paralysis is rarely complete for any long period of time; in this respect it differs from the absolute paralysis due to destruction of anterior horn cells or interruption of their axons Upper motor neuron lesions are characterized further by certain peculiarities of residual movement There is decreased voluntary drive on spinal motor neurons (fewer motor units are recruitable and their ring rates are slower), resulting in a slowness of movement There is also an increased degree of cocontraction of antagonistic muscles, re ected in a decreased rate of rapid alternating movements These abnormalities probably account for the greater sense of effort and the manifest fatigability in effecting voluntary movement of the weakened muscles Another phenomenon is the activation of paralyzed muscles as parts of certain automatisms (synkinesias) The paralyzed arm may move suddenly during yawning and stretching Attempts by the patient to move the hemiplegic limbs may result in a variety of associated movements Thus, exion of the arm may result in involuntary pronation and exion of the leg or in dorsi exion and eversion of the foot Also, volitional movements of the paretic limb may evoke imitative (mirror) movements in the normal one or vice versa In some patients, as they recover from hemiplegia, a variety of movement abnormalities emerge, such as tremor, ataxia, athetosis, and chorea on the affected side These are expressions of damage to basal ganglionic and thalamic structures and are discussed in Chap 4 If the upper motor neurons are interrupted above the level of the facial nucleus in the pons, hand and arm muscles are affected most severely and the leg muscles to a lesser extent; of the cranial musculature, only muscles of the tongue and lower part of the face are involved to any signi cant degree Since Broadbent was the rst to call attention to this distribution of facial paralysis, it is sometimes referred to as Broadbent s law The precise course taken by bers that innervate the facial nucleus is still somewhat uncertain, as described earlier, under Anatomic and Physiologic Considerations ; but it is clear that some descend to the upper medulla and then ascend recurrently to the pons This accounts for the mild facial weakness that is seen with lesions of the lower pons and upper medulla At lower levels, such as the cervical cord, complete acute lesions of the upper motor neurons not only cause a paralysis of voluntary movement but also abolish temporarily the spinal re exes subserved by segments below the lesion This is the condition referred to above as spinal shock, a state of acute accid paralysis that is replaced later by spasticity A comparable state of shock may occur with acute cerebral lesions but is less sharply de ned than is the spinal state With some acute cerebral lesions, spasticity and paralysis develop together; in others, especially with parietal lesions, the limbs remain accid but re exes are retained Spasticity, Hyperre exia, and the Babinski Sign A predilection for involvement of certain muscle groups, a speci c pattern of response of muscles to passive stretch (where resistance increases linearly in relation to velocity of stretch), and a manifest exaggeration of tendon re exes are the identifying characteristics of spasticity The antigravity muscles the exors of the arms and the extensors of the legs are predominantly affected The arm tends to assume a exed and pronated position and the leg an extended and adducted one, indicating that certain spinal neurons are re exly.

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