A clinical and investigative approach to the patient with diminished responsiveness.
Neurol Clin. 2011 Nov;29(4):739-47
Authors: Hocker S, Rabinstein AA
Abstract
This article elucidates a stepwise approach to t…

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Neurotoxic emergencies.
Neurol Clin. 2011 Aug;29(3):539-63
Authors: Barry JD, Wills BK
Neurotoxic emergencies are depicted by severe disruption of critical central or peripheral nervous system functions caused by xenob…

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Diagnostic testing for migraine and other primary headaches.

Neurol Clin. 2009 May;27(2):393-415

Authors: Evans RW

Most primary headaches can be diagnosed using the history and examination. Judicious use of neuroimaging and other testing, however, is indicated to distinguish primary headaches from the many secondary causes that may share similar features. This article evaluates the reasons for diagnostic testing and the use of neuroimaging, electroencephalography, lumbar puncture, and blood testing. The use of diagnostic testing in adults and children who have headaches and a normal neurologic examination, migraine, trigeminal autonomic cephalalgias, hemicrania continua, and new daily persistent headache are reviewed.

PMID: 19289222 [PubMed - indexed for MEDLINE]

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Progressive multifocal leukoencephalopathy.

Neurol Clin. 2008 Aug;26(3):833-54, x-xi

Authors: Weber T

Progessive multifocal leukoencephalopathy (PML) incidence has increased about fivefold due to the AIDS pandemic. The disease has an insidious onset with HIV infection as underlying illness in 85% of cases and may present with any combination of weakness, speech disturbances, limb incoordination, cognitive deficits, and visual impairment. Diagnosis is obtained by MRI with high sensitivity but low specificity revealing T2-hyperintense, small to large, sometimes confluent lesions in the white matter, sparing the subcortical U-fibers. A spinal tap can be used to diagnose PML by JC viral DNA amplification with a sensitivity of 80% and a specificity approximating 100%. Effective therapy is either cessation of immunosuppressive therapy in cancer patients or successful restoration of the immune system in HIV infection.

PMID: 18657729 [PubMed - indexed for MEDLINE]

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Rabies.

Neurol Clin. 2008 Aug;26(3):717-26, ix

Authors: Jackson AC

Rabies remains an important public health problem in developing countries, and the indigenous threat of rabies continues in developed countries because of wildlife reservoirs. A diagnosis of rabies is often not considered by physicians until late in the clinical course or after death in North America and Europe, even with typical clinical presentations. Transmission of rabies virus has occurred in association with transplantation of tissues and also recently with organs. In 2004 a young patient survived rabies in Wisconsin, but the reasons for this favorable outcome remain elusive. This article reviews current information and developments on a variety of neurologic aspects of rabies.

PMID: 18657723 [PubMed - indexed for MEDLINE]

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Management of acute ischemic stroke.

Neurol Clin. 2008 May;26(2):345-71, vii

Authors: Finley Caulfield A, Wijman CA

Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the management of acute ischemic stroke, including conventional and novel therapies. The article provides an overview of the initial management, diagnostic work-up, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.

PMID: 18514817 [PubMed - indexed for MEDLINE]

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Management of spontaneous intracerebral hemorrhage.

Neurol Clin. 2008 May;26(2):373-84, vii

Authors: Naval NS, Nyquist PA, Carhuapoma JR

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

PMID: 18514818 [PubMed - indexed for MEDLINE]

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Updates in the management of seizures and status epilepticus in critically ill patients.

Neurol Clin. 2008 May;26(2):385-408, viii

Authors: Abou Khaled KJ, Hirsch LJ

Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are nonconvulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to firstline treatment and to prevent neurologic and systemic sequelae. Antiseizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.

PMID: 18514819 [PubMed - indexed for MEDLINE]

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Update in the diagnosis and management of central nervous system infections.

Neurol Clin. 2008 May;26(2):427-68, viii

Authors: Ziai WC, Lewin JJ

Central nervous system (CNS) infections presenting to the emergency room include meningitis, encephalitis, brain and spinal epidural abscess, subdural empyema, and ventriculitis. These conditions often require admission to an intensive care unit (ICU) and are complications of ICU patients with neurologic injury, contributing significantly to morbidity and mortality. Reducing morbidity and mortality is critically dependent on rapid diagnosis and, perhaps more importantly, on the timely initiation of appropriate antimicrobial therapy. New insights into the role of inflammation and the immune response in CNS infections have contributed to development of new diagnostic strategies using markers of inflammation, and to the study of agents with focused immunomodulatory activity, which may lead to further adjunctive therapy in human disease.

PMID: 18514821 [PubMed - indexed for MEDLINE]

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Types of brain dysfunction in critical illness.

Neurol Clin. 2008 May;26(2):469-86, ix

Authors: Stevens RD, Nyquist PA

Cerebral dysfunction and injury in the ICU presents as focal neurologic deficits, seizures, coma, and delirium. These syndromes may result from a primary brain insult, such as stroke or trauma, but commonly are a complication of a systemic insult, such as cardiac arrest, hypoxemia, sepsis, metabolic derangements, and pharmacologic exposures. Many survivors of critical illness have cognitive impairment, which is believed to underlie the poor long-term functional status and quality of life observed in many critical illness survivors. Although progress has been made in characterizing the epidemiology of cerebral dysfunction in the ICU, more research is needed to elucidate underlying mechanisms that might represent targets for therapeutic intervention.

PMID: 18514822 [PubMed - indexed for MEDLINE]

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Management of brain injury after resuscitation from cardiac arrest.

Neurol Clin. 2008 May;26(2):487-506, ix

Authors: Geocadin RG, Koenig MA, Jia X, Stevens RD, Peberdy MA

The devastating neurologic injury in survivors of cardiac arrest has been recognized since the development of modern resuscitation techniques. After numerous failed clinical trials, two trials showed that induced mild hypothermia can ameliorate brain injury and improve survival and functional neurologic outcome in comatose survivors of out-of-hospital cardiac arrest. This article provides a comprehensive review of the advances in the care of brain injury after cardiac arrest, with updates on the process of prognostication, the use of therapeutic hypothermia and adjunctive intensive care unit care for cardiac arrest survivors.

PMID: 18514823 [PubMed - indexed for MEDLINE]

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Critical illness neuromuscular syndromes.

Neurol Clin. 2008 May;26(2):507-20, ix

Authors: De Jonghe B, Lacherade JC, Durand MC, Sharshar T

Critical illness neuromyopathy (CINM) is suggested by bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of critical illness. Although muscle and peripheral nerve are often involved in combination, muscle involvement alone is increasingly identified on electrophysiologic investigation, including direct muscle stimulation. CINM frequently involves the respiratory muscles and may result in delayed weaning and prolonged mechanical ventilation. Besides muscle immobilization and prolonged sepsis-induced multiorgan failure, which are risk factors for CINM, hyperglycemia and use of corticosteroids might have a deleterious effect on the neuromuscular system in critically ill patients, suggesting opportunities for preventive interventions.

PMID: 18514824 [PubMed - indexed for MEDLINE]

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Management of intracranial hypertension.

Neurol Clin. 2008 May;26(2):521-41, x

Authors: Rangel-Castillo L, Gopinath S, Robertson CS

Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.

PMID: 18514825 [PubMed - indexed for MEDLINE]

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Blood pressure management in acute stroke.

Neurol Clin. 2008 May;26(2):565-83, x-xi

Authors: Urrutia VC, Wityk RJ

The optimal management of arterial blood pressure in the setting of an acute stroke has not been defined. Many articles have been published on this topic in the past few years, but definitive evidence from clinical trials continues to be lacking. This situation is complicated further because stroke is a heterogeneous disease. The best management of arterial blood pressure may differ, depending on the type of stroke (ischemic or hemorrhagic) and the subtype of ischemic or hemorrhagic stroke. This article reviews the relationship between arterial blood pressure and the pathophysiology specific to ischemic stroke, primary intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage, elaborating on the concept of ischemic penumbra and the role of cerebral autoregulation. The article also examines the impact of blood pressure and its management on outcome. Finally, an agenda for research in this field is outlined.

PMID: 18514827 [PubMed - indexed for MEDLINE]

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