Seminars in neurology
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Seminars in neurology · Dec 2016
ReviewCritical Care of Traumatic Cervical Spinal Cord Injuries: Preventing Secondary Injury.
The incidence of traumatic spinal cord injury (SCI) has not changed much over the years due to an aging population suffering falls, yet advances have been made in quality of life and survival time. In addition to initial medical and surgical stabilization, modern intensive care unit (ICU) care throughout the critical early period following SCI is essential to avoid continued secondary injury to the spinal cord. Cervical SCI patients are particularly prone and sensitive to periods of cardiovascular instability and respiratory failure directly resulting from their injuries. Preclinical and class III clinical data suggest improved outcomes by maintaining the mean arterial pressure > 85 mm Hg and avoiding hypoxemia at least for 7 days following cervical SCI, and this level of monitoring and support should occur in the ICU.
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The evidence linking delirium to poor outcomes after critical illness is compelling, including higher mortality, prolonged mechanical ventilation, longer length of intensive care unit stay, and long-term cognitive impairments. The attitude toward delirium in the neurologic community is shifting away from viewing it as an unmodifiable, inevitable consequence of severe illness to treating it is as a neurologic emergency, akin to seizures or encephalitis. Delirium, like other manifestations of critical illness encephalopathy, is an organ dysfunction syndrome. ⋯ There is scant evidence for directed pharmacological treatment of delirium, but multicomponent care bundles that address the management of pain, agitation, sedation, and delirium are effective at reducing the burden of delirium in the general intensive care unit population. The management of delirium in the neurologic intensive care environment is mostly extrapolated from studies on general medical critical illness and noncritically ill neurologic patients. Further investigation into the unique risks and management needs of critically ill neurologic and neurosurgical patients is needed to reduce the burden of delirium in that population.
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Intracerebral hemorrhage (ICH) is associated with devastating outcomes. Admission to the intensive care unit has been the only proven course to improve outcomes. All other treatment modalities have failed so far. ⋯ In fact, the results of three subsequent meta-analyses also showed safety and possible efficacy of early lowering of BP in ICH. Based on the results of the published clinical trials and meta-analyses, the American Heart Association and the European Stroke Association concluded that early intensive treatment of BP in acute ICH is safe and might improve functional outcome. The authors advocate that-pending additional data from ongoing trials-health care professionals should maintain the SBp < 140 mm Hg in patients presenting with acute ICH.
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Neuropathic pain (NP), a common form of human pain, often poorly responds to analgesic medications. In this review the authors discuss the pathophysiology and conventional treatment of neuropathic pain and provide evidenced-based statements on the efficacy of botulinum neurotoxins (BoNTs) in this form of pain. The level of efficacy for BoNT treatment in each category of NP is defined according to the published guidelines of the American Academy of Neurology. ⋯ It is probably effective (level B) in posttraumatic neuralgia and painful diabetic neuropathy. The data on complex regional pain syndrome, carpal tunnel syndrome, occipital neuralgia, and phantom limb pain are preliminary and await conduction of randomized, blinded clinical trials. Much remains to be learned about the most-effective dosage and technique of injection, optimum dilutions, and differences among BoNTs in the treatment of neuropathic pain.
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Seminars in neurology · Feb 2016
The Use of Botulinum Toxin in the Management of Headache Disorders.
Headache disorders can be further classified as episodic (< 15 headache days per month) or chronic (≥ 15 headache days per month for more than 3 months). Chronic migraine (CM) requires that headaches occur on 15 or more days a month for more than 3 months. These headaches must be migraines on at least 8 days per month. ⋯ Botulinum toxin type A (BoNT-A) has been the most widely studied serotype for therapeutic purposes. A major clinical advantage of type A toxin arises from its prolonged duration of action due to the longevity of its protease (90 days in rats and probably much longer in human neurons). Clinical studies suggest that BoNT is a safe treatment and is efficacious for the prevention of some forms of migraine, such as CM, and perhaps high-frequency episodic migraine.