Seminars in neurology
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In this article, isolated palsies of cranial nerves III, IV, and VI are addressed. After discussion of the pertinent clinical anatomy of cranial nerves III, IV, and VI, the isolated involvement of each of these oculomotor nerves is defined. Based on a review of the literature, methods of evaluation and follow-up of patients presenting with diplopia from lesions of these cranial nerves are presented.
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The sense of smell is greatly underappreciated, despite the fact that it monitors the intake of airborne agents into the human respiratory system and determines to a large degree the flavor and palatability of foods and beverages. In addition to enhancing quality of life, this primary sensory system warns of spoiled foods, leaking natural gas, polluted air and smoke, and mediates basic elements of communication (e.g., mother-infant interactions). It is now apparent that smell dysfunction is among the first clinical signs of such neurodegenerative diseases as Alzheimer's disease and sporadic Parkinson's disease. In this brief article, the author reviews the anatomy and physiology of this primary sensory system, means of assessing its function, and major diseases and disorders with which it is intimately associated.
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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.
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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.