Seminars in neurology
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Seminars in neurology · Jul 2013
ReviewClinical characteristics of cervicogenic-related dizziness and vertigo.
Cervical vertigo has long been a controversial entity and its very existence as a medical entity has advocates and opponents. Supporters of cervical vertigo claim that its actual prevalence is underestimated due to the overestimation of other diagnostic categories in clinics. ⋯ A clinical entity named subclinical vertebrobasilar insufficiency appears in the context of cervical osteoarticular changes. Migraine-associated vertigo may explain why some patients suffering from cervical pain have vertigo while others do not.
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Acute continuous vertigo presentations are among the most feared presentations in medicine. Although a self-limited disorder is the typical cause, a life-threatening stroke can also occur. Differentiating a self-limited disorder from a life-threatening stroke can be a challenge. ⋯ A focused oculomotor examination is a necessary component of the assessment, but is underused in routine care. The author describes the challenges to diagnosing stroke in cases of acute continuous vertigo and provides an approach to inform decision making at the bedside. Future research is necessary to validate clinical decision support, assess generalizability, and demonstrate its impact on meaningful outcomes.
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Seminars in neurology · Apr 2013
ReviewThe acutely comatose patient: clinical approach and diagnosis.
A patient's acute and persistent unresponsiveness in the emergency department often triggers a neurology consultation. Given the many potential causes of unresponsiveness, the initial objective of the neurologist should be a comprehensive history and physical examination, which should allow localization of the lesion, if possible, and an initial narrowing of the differential diagnosis. In addition, neuroimaging review and laboratory evaluation have come to play an increasingly important role in identification of the potential causes of unresponsiveness. ⋯ The neurologist is adept at correctly moving through a differential diagnosis and this has a profound effect on management. Once appropriate treatment has been initiated, the outcome can be assessed. Recovery from coma can be prolonged, but is less likely if early involvement of the brainstem is apparent.
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Seminars in neurology · Apr 2013
Review Historical ArticleComa and disorders of consciousness: scientific advances and practical considerations for clinicians.
Recently, neuroscientists and clinicians have seen the rapid evolution of diagnoses in disorders of consciousness. The unresponsive wakefulness syndrome-vegetative state, the minimally conscious state plus and minus, and the functional locked-in syndrome have been defined using new neuroimaging techniques. ⋯ However, low sensitivity and artifacts problems need to be solved to bring these new technologies to the single-patient level; they also need to be studied in larger scale and randomized control trials. In addition, new ethics questions have arisen and need to be investigated.
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Seminars in neurology · Apr 2013
ReviewEnd-of-life and brain death in acute coma and disorders of consciousness.
Consulting neurologists are often asked to evaluate patients in acute nontraumatic coma. The authors review prognostication of functional outcomes, determining brain death, and managing end-of-life care. Prognostication of outcome after cardiac arrest in comatose patients is a frequently encountered scenario with high-stakes implications. ⋯ Brain death is a clinical condition of irreversible coma of known cause with absent brainstem reflexes and apnea. An understanding of the value of confirmatory testing and the potential for confounding factors is essential in making a correct diagnosis. As coma carries a high mortality rate, neurologists must be capable of guiding goals of care, discussing end-of-life issues, and understanding organ-procurement procedures.