Neurologic clinics
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It is essential to control arterial blood pressure (BP) in both hemorrhagic and ischemic stroke patients to decrease morbidity following an acute event and decrease the long-term risk of stroke recurrence. Pathophysiology of BP control is dependent on understanding key relationships of cerebral blood flow and cerebral perfusion pressure. ⋯ There are several different drug classes available for BP control, with considerable debate as to which drugs are preferred for stroke patients. Medication selection and target BP depend on individual patient characteristics, including type of stroke, medical comorbidities, and timing of interventions in the context of the acute or postacute phases of stroke.
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Although headache is a common ailment, its more severe manifestations such as intractable migraine, and trigeminal autonomic cephalagias including cluster headaches have a debilitating effect on patients resulting in chronic pain and severe functional impairment. Neurostimulation has been explored as a possible treatment option in selective drug-resistant primary headache disorders, in conducting clinical trials involving neurostimulation of deep brain structures, occipital nerves, and vagal nerves as treatment methods for refractory primary headache disorders, the selection of patients should be strictly based on pre-defined clinical criteria. The trials should be well designed, taking into account the potential risks and complications associated with such therapies.
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Motor fluctuations and dyskinesias are common motor complications that manifest within the first few years from the initiation of therapy in patients with Parkinson disease. These complications negatively affect the quality of life and represent an important source of disability. ⋯ Patients who maintain a good response to levodopa but continue to experience disabling motor complications despite the best medical management may benefit from a regimen of subcutaneous apomorphine, ideally delivered by a subcutaneous pump, or deep-brain stimulation of the subthalamic nucleus or internal portion of the pallidum. Emerging therapies for motor complications are expected to further enhance continuous (physiologic) delivery of dopaminergic drugs and extend the reach of therapies beyond the dopaminergic system to influence not only the motor but also the vast range of nonmotor complications of this multisystemic disease.
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Classification, pathophysiology, and endovascular treatment of intracranial dural arteriovenous fistulas are discussed. Risk for neurologic deterioration is based on the presence and extent of cortical venous reflux. ⋯ Recent advances in endovascular materials have facilitated the treatment and cure of many of these lesions via transarterial approaches. Penetration of liquid embolic agent into the nidus and foot of the draining vein is crucial for long-term angiographic cure.