Seminars in neurology
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Seminars in neurology · Nov 2008
ReviewAutonomic complications following central nervous system injury.
Severe sympathetic overactivity occurs in several conditions that are recognized as medical emergencies. Following central nervous system injury, a small proportion of individuals develop severe paroxysmal sympathetic and motor overactivity. These individuals have a high attendant risk of unnecessary secondary morbidity. ⋯ This review presents a current understanding of each condition and suggests simple management protocols. With the marked disparity in the literature for the two conditions, the main focus is on the literature for dysautonomia. The similarity between these two conditions and the other autonomic emergency conditions is discussed.
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Neurological injury resulting from cardiac surgery has a range of manifestations from focal neurological deficit to encephalopathy or coma. As the safety of drug-eluting stents comes into question, more patients will likely undergo coronary artery bypass graft surgery. These projections, along with the growing proportions of elderly patients and those with comorbidities, portend the potential for rising rates of perioperative neurological complications. ⋯ Changes in surgical techniques, including the use of off-pump surgery, have not decreased rates of brain injury from cardiac surgery. When appropriate, modern neuroimaging techniques should be used in postoperative patients to confirm diagnosis, to provide information on potential etiology, to direct appropriate therapy, and to help in prognostication. Management of postoperative medications and early use of rehabilitation services is a recommended strategy to optimize the recovery for individuals with neurological injury after cardiac surgery.
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The management of severe brain injury requires a comprehensive approach in which imaging is an indispensable complement to the clinical and physiological information acquired at the bedside. Neuroimaging methods are routinely used in the diagnosis and prognosis of a broad spectrum of patients with acute neurological dysfunction. With incremental theoretical and technological refinements, imaging modalities are helping to unravel fundamental questions regarding the pathophysiology and neuroplasticity associated with critical neurological injury, and it is anticipated that this knowledge will lead to new and effective therapeutic interventions. We review some of the established and emerging structural and physiological imaging methods, and discuss their applications in patients with critical injuries including trauma and encephalopathy due to anoxia, liver failure, and sepsis.
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Acute ischemic stroke is a common disorder with a significant impact on morbidity and mortality in the United States. The number of interventions for acute stroke patients has increased over the past 15 years and patients increasingly require intensive care. There are several issues that are specific to ischemic stroke patients in intensive care unit (ICU) settings, including the care of the postthrombolytic stroke patient, respiratory issues in stroke care, evaluation of worsening or change in neurological status, and attention to factors that affect the ischemic penumbra. The management of the stroke patient in the critical care setting is discussed in this article.
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Intracerebral hemorrhage (ICH) accounts for 10 to 15% of all strokes, but results in a disproportionately high morbidity and mortality. Although chronic hypertension accounts for the majority of ICH, other common causes include cerebral amyloid angiopathy, sympathomimetic drugs of abuse, and underlying cerebral vascular anomalies. Validated baseline predictors of clinical outcome after ICH include the Glasgow Coma Scale score, hematoma volume, presence and amount of intraventricular hemorrhage, infratentorial ICH location, and advanced age. ⋯ Basic research has suggested that perihematoma injury is more likely related to toxicity of blood and iron in the brain ("neurohemoinflammation") rather than primary ischemic injury. Current guidelines for ICH treatment emphasize blood pressure management, urgent and rapid correction of coagulopathy, and surgery for cerebellar ICH. Ongoing clinical trials are investigating surgical evacuation of lobar hemorrhage, minimally invasive surgical hematoma evacuation, and aggressive blood pressure lowering.