Seminars in neurology
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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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Imaging of the pediatric brain is challenging. Knowledge of the normal anatomy and appearance of the developing brain at a given age is critical in identifying abnormalities. Brain malformations had been in the domain of the neuropathologist, but with advanced neuroimaging they can be defined in vivo. ⋯ In addition to anatomical magnetic resonance (MR) imaging, metabolic imaging with MR spectroscopy is established in many brain disorders, such as tumors, leukodystrophies, and metabolic conditions. Even though catheter angiography remains the gold standard, MR and computed tomography angiography provide rapid and noninvasive alternatives to evaluate children with vascular lesions. This article presents the classic imaging findings in pediatric neurology, including the commonly seen malformations, metabolic disorders, and trauma in addition to some rarer diseases.
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Head trauma requires several different neuroimaging modalities for adequate evaluation and determination of treatment. This article considers the importance of anatomical and functional imaging modalities in the initial evaluation, treatment planning, and long-term management of patients with head injury. ⋯ Each modality offers specific advantages and potential disadvantages. However, it is important to understand the capabilities of each modality, and how and when each one might provide the most valuable information as one evaluates such patients.
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Status epilepticus (SE) is a neurological emergency that requires prompt diagnosis and treatment, as delay is associated with a higher likelihood of poor response to treatment and worse outcome. Lorazepam has been well established as a first-line therapy. Subsequent steps are less established, and there are many reasonable options, including intravenous fosphenytoin, valproate, midazolam, propofol, and phenobarbital. ⋯ For refractory SE, continuous intravenous midazolam and propofol, separately or in combination, are rapidly effective, with pentobarbital remaining the gold standard for prolonged cases. If a patient does not awaken after treatment, urgent electroencephalogram (EEG) should be obtained to rule out nonconvulsive seizure activity. In refractory SE, continuous EEG monitoring is required to recognize recurrence of seizure activity, as most seizures will be nonconvulsive.