Seminars in neurology
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Intracranial hypertension implies profoundly disturbed intracranial physiology. Although a shared manifestation of myriad neurological disorders of patients admitted in the intensive care unit (ICU), the pathways leading to intracranial hypertension vary by etiology. ⋯ Several integrated management paradigms have been used to treat intracranial hypertension. Regrettably, there is a dearth of randomized clinical trials to confirm the efficacy of even our most routine therapeutic strategies.
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Seminars in neurology · Nov 2008
ReviewPreoperative evaluation of patients with neurological disease.
A thorough evaluation of patients with neurological diseases undergoing surgery can reduce perioperative morbidity and mortality, especially stroke. Various neurological disorders and neurosurgical procedures may influence the nature and extent of preoperative evaluation, selection and conduct of anesthesia, and perioperative management and care. Although anesthesiologists primarily perform a preoperative evaluation of neurological patients, neurologists can contribute further valuable information about the neurological condition and perioperative management of various neurological diseases to obtain the best possible outcome. This article outlines the basic elements of preoperative evaluation and highlights specific considerations for neurological patients undergoing surgery.
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Persistent seizures and failure to regain consciousness following witnessed seizure activity require emergency neurological consultation. Although outcome is largely dependent on underlying cause, early maximal anticonvulsant therapy is critical to reducing morbidity. This review covers important concepts in the clinical and EEG diagnosis of status epilepticus, and discusses treatment algorithms for single and recurrent seizures, emphasizing the need to rationalize therapy depending on the presumed duration of seizure activity. The review takes the perspective of the neurological consultant in the intensive care unit, and considers all pharmacological approaches available to the intensivist as described in the current literature and from clinical experience.
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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.