Seminars in neurology
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Neurosurgical disorders are a significant cause of nonobstetric death and disability in pregnant women. The most common neurosurgical conditions encountered are intracranial hemorrhage, hydrocephalus, intracranial tumors, disc rupture, and head trauma. ⋯ Intracranial hemorrhage can sometimes be followed conservatively if it is not life-threatening; shunted hydrocephalus may get worse during the later stages of pregnancy but can usually be followed; meningiomas and pituitary adenomas may increase in size and require urgent surgical decompression because of apoplexy; disc ruptures can usually be treated conservatively; head trauma should be treated in the same way as in a nonpregnant patient. This article discusses several surgical and anesthetic issues that are important in dealing with these conditions.
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The subject of brain death usually becomes clinically relevant during a tremendously stressful time. For most practitioners, the need to make a diagnosis of brain death occurs infrequently. ⋯ The historical background and the current standards and guidelines used to diagnose brain death will be reviewed. Potential future changes in brain death criteria when contemplating organ donation in the critically ill patient will be discussed.
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Ischemic optic neuropathies (IONs) are the most frequent acute optic neuropathy in patients older than 50 years. They are classified according to the location of the ischemic damage into anterior ION and posterior ION. Ischemic optic neuropathies may also be categorized based on the presence or absence of temporal arteritis as an underlying etiology. ⋯ Examination findings usually include decreased visual acuity, a visual field defect, color vision loss, a relative afferent pupillary defect, and a swollen optic nerve head. Posterior ION occurs in arteritic, nonarteritic, and surgical settings. It is characterized by acute vision loss without initial disc edema but with subsequent optic disc atrophy.
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It is well recognized that headache, and especially migraine, runs in families. Recent studies into the heritability of primary headache subtypes, migraine, cluster and tension headache, and conditions in which headache is a prominent feature, such as the mitochondrial disease, mitochondrial encephalopathy, lactic acidosis, and strokelike episodes, and the arteriopathy, cerebral autosomal-dominant arteriopathy with subcortical infarctions and leukoencephalopathy, are improving our understanding of the genetic contribution to headache. Studies of the rare familial hemiplegic migraine are leading to advances in understanding the pathophysiological mechanisms of the more common migraine types. Current knowledge of hereditary and genetic features of headache subtypes is reviewed and the implications for understanding the pathophysiology of migraine are discussed.
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Seminars in neurology · Sep 2006
ReviewEthical issues in critical care and cardiac arrest: clinical research, brain death, and organ donation.
Cardiac arrest results in global hypoxic-ischemic brain injury from which there is a range of possible neurological outcomes. In most cases, patients may require a surrogate to make decisions regarding end-of-life care, including the withdrawal of life-sustaining therapies. This article reviews ethical considerations that arise in the clinical care of patients following cardiac arrest, including decisions to continue or withdraw life-sustaining therapies; brain death determination; and organ donation in the context of brain death and cardiac death (so-called non-heart-beating donation). This article also discusses ethical concerns pertaining to the design and conduct of resuscitation research that is necessary for the development of effective therapies to prevent anoxic brain injury or promote neurological recovery.