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Mental signs are said to be frequent, ranging from irritability, apathy, somnolence, suspiciousness, and emotional instability to a marked confusional or depressive psychosis or intellectual deterioration Lindenbaum and coworkers have reported cases in which neuropsychiatric symptoms, responsive to vitamin B12, were present without spinal cord or peripheral nerve abnormalities In our clinical material, symptoms of dementia have not been frequent and always followed the spinal cord disorder Visual impairment due to optic neuropathy may occasionally be the earliest or sole manifestation of pernicious anemia; examination discloses roughly symmetrical centrocecal scotomata and optic atrophy in the most advanced cases (page 215) The fact that visual evoked potentials may be abnormal in vitamin B12 de cient patients without clinical signs of visual impairment suggests that the visual pathways may be affected more often than is evident from the neurologic examination alone.

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Let s see how this works by walking through the execution of the example in architecture sequential, line by line. To be consistent, let s assume that s0 changes to 0. Because s0 is in the sensitivity list for the process statement, the process is invoked. Each statement in the process is then executed sequentially. In this example the IF statement is executed first followed by the CASE statment. Each check that the IF statement performs is done sequentially starting with the first in the model. The first check is to see if s0 is equal to a 0. This statement fails because s0 is equal to a 1 and s1t is equal to a 0. The signal assignment statement that follows the first check will not be executed. Instead, the next check is performed. This check succeeds and the signal assignment statements following the check for s0 = 1 and s1 = 0 are executed. This statement is shown below.

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A small number of patients have symptoms of autonomic dysfunction, including urinary sphincteric symptoms and impotence The CSF is usually normal; in some cases there is a moderate increase in protein The EMG shows slowing of sensory conduction or reduced-amplitude sensory potentials Almost always, according to Hemmer and colleagues, somatosensory evoked potentials reveal delayed conduction or absent responses; these changes are known to recover with treatment Quite remarkable, as these authors indicate, is the nding on MRI of a T2 signal change that demarcates the posterior columns of the cord, as shown in Fig 41-1 In two of our cases, these have taken the form of well-de ned linear changes within the posterior columns on axial scans of the cervical cord Neuropathologic Changes The pathologic process takes the form of a diffuse though uneven degeneration of white matter of the spinal cord and occasionally of the brain.

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The earliest histologic event is a swelling of myelin sheaths, characterized by the formation of intramyelinic vacuoles and separation of myelin lamellae This is followed by a coalescence of small foci of tissue destruction into larger ones, imparting a vacuolated, sieve-like appearance to the tissue an appearance also observed in the myelopathy of AIDS and rarely in lupus erythematosus The myelin sheaths and axis cylinders are both involved in the degenerative process, the former more obviously and perhaps earlier and more severely than the latter There is relatively little brous gliosis in the early lesions, but in more chronic ones, particularly those in which considerable tissue is destroyed, the gliosis is pronounced The changes begin in the posterior columns of the lower cervical and upper thoracic segments of the cord and spread from this region up and down the cord as well as forward into the lateral and anterior columns.

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The lesions are not limited to speci c systems of bers within the pos-.

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