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This is the most frequent form of paralysis With rare exceptions (a few unusual cases of poliomyelitis or motor system disease), this pattern of paralysis is due to involvement of the corticospinal pathways The site or level of the lesion ie, cerebral cortex, corona radiata, capsule, brainstem, or spinal cord can usually be deduced from the associated neurologic ndings Diseases localized to the cerebral cortex, cerebral white matter (corona radiata), and internal capsule usually manifest themselves by weakness or paralysis of the leg, arm, and lower face on the opposite side The occurrence of seizures or the presence of a language disorder (aphasia), a loss of discriminative sensation (astereognosis, impairment of tactile localization, etc), anosognosia, or a homonymous visual eld defect suggests a contralateral cortical or subcortical location Damage to the corticospinal and corticobulbar tracts in the upper portion of the brainstem also causes paralysis of the face,

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arm, and leg of the opposite side (see Fig 3-2) The lesion in such cases may in some patients be localized by the presence of a third nerve palsy (Weber syndrome) or other segmental abnormality on the same side as the lesion (opposite the hemiplegia) With low pontine lesions, an ipsilateral abducens or facial palsy is combined with a contralateral weakness or paralysis of the arm and leg (Millard-Gubler syndrome) Lesions in the medulla affect the tongue and sometimes the pharynx and larynx on one side and the arm and leg on the other These crossed paralyses, so characteristic of brainstem lesions, are described further in Chap 34 Even lower in the medulla, a unilateral infarct in the pyramid causes a accid paralysis followed by slight spasticity of the contralateral arm and leg, with sparing of the face and tongue Some motor function may be retained, as in the case described by Ropper and colleagues; interestingly, in this case and in others previously reported, there was considerable recovery of voluntary power even though the pyramid was almost completely destroyed Rarely, an ipsilateral hemiplegia may be caused by a lesion in the lateral column of the cervical spinal cord In this location, however, the pathologic process more often induces bilateral signs, with resulting quadriparesis or quadriplegia A homolateral paralysis that spares the face, if combined with a loss of vibratory and position sense on the same side and a contralateral loss of pain and temperature, signi es disease of one side of the spinal cord (BrownSequard syndrome, as discussed in Chap 44) As indicated above, muscle atrophy that follows upper motor neuron lesions never reaches the proportions seen in diseases of the lower motor neuron The atrophy in the former cases is due to disuse When the motor cortex and adjacent parts of the parietal lobe are damaged in infancy or childhood, normal development of the muscles as well as the skeletal system in the affected limbs is retarded The limbs and even the trunk are smaller on one side than on the other This does not happen if the paralysis occurs after puberty, by which time the greater part of skeletal growth has been attained In hemiplegia due to spinal cord lesions, muscles at the level of the lesion may atrophy as a result of damage to anterior horn cells or ventral roots In the causation of hemiplegia, ischemic and hemorrhagic vascular diseases of the cerebrum and brainstem exceed all others in frequency Trauma (brain contusion, epidural and subdural hemorrhage) ranks second Other important causes, less acute in onset, are, in order of frequency, brain tumor, brain abscess, demyelinative diseases, and the vascular complications of meningitis and encephalitis Most of these diseases can be recognized by their mode of evolution and characteristic clinical and laboratory ndings, which are presented in the chapters on neurologic diseases Alternating transitory hemiparesis may be due to a special type of migraine (see discussion in Chap 10) From time to time, hysteria is found to be the cause of a hemiplegia, as discussed further on.

The act of swallowing, like breathing, continues periodically through waking and sleep, largely without conscious will or awareness Swallowing occurs at a natural frequency of about once per

As for each of the chart types, I did several formatting adjustments, but all of the parameters are available directly from the Edit Chart Designer component Initially I used the wizard to assign the titles to each of the axes and to the top of the chart This is shown in the following illustration It s important that you fill in all three titles Category, Value Axis, and actual Title

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