Neurologic clinics
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Diabetic neuropathies are the most common types of neuropathies worldwide. Although there has been significant progress in the understanding of the clinical aspects of these conditions, many questions remain unanswered or difficult to answer in terms of causation, risk factors and genetic susceptibility, effective treatments and restoration of nerve functions, and pain management. ⋯ Unfortunately and despite numerous drug trials, other than strict glycemic control, which is often difficult to maintain, there are no other treatments to slow the progression or delay the development of diabetic neuropathy. This article attempts to highlight a few unanswered or controversial questions regarding diabetic neuropathies.
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Review Comparative Study
Current options in clipping versus coiling of intracranial aneurysms: to clip, to coil, to wait and watch.
Treatment of intracranial aneurysms involves many factors: patient preference and demographics; aneurysm size, site, geometry, access, and intrinsics; practitioner experience and availability; facility; technology; and ancillaries. Volume counts, teamwork enhancement, and management should be individualized.
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All neuromonitoring techniques, although imperfect, provide useful information for monitoring cardiothoracic and carotid vascular operations. They may be viewed as providing complementary information, which may help surgical technique and, as a result, possibly improve clinical outcomes. As of this writing, the efficacy of TCD and NIRS monitoring during cardiothoracic and vascular surgery cannot be considered established. Well designed, prospective, adequately powered, double-blind, and randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities), in specific surgical settings.
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Decompressive surgery with hemicraniectomy and durotomy for malignant MCA infarction remains a salvage procedure but can be associated with reasonable clinical outcomes in highly selected patients. This selection of patients appropriate for intervention is of the utmost importance, but exact criteria remain to be defined; older age and increased numbers of associated medical comorbidities seem to define a group of patients who would not derive long term benefit, however. ⋯ Clinicians managing the growing population of patient status post hemicraniectomy should also be aware of this process of the syndrome of the trephined and the potential for resolution that may prompt earlier cranial reconstruction. At present, the decision to proceed with this aggressive intervention of hemicraniectomy and durotomy for large ischemic infarction remains a case-by-case individualized approach, based on patient and family preferences and clinicians' subjective perspective as to patients' potential for clinical recovery.
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Patients who have cerebrovascular disease and vascular insufficiency routinely have neurosurgical and nonneurosurgical procedures. Anesthetic priorities must provide a still bloodless operative field while maintaining cardiovascular stability and renal function. ⋯ Optimization of current condition is important for a good outcome; risks must be weighed against perceived benefits in protecting neurons. Anesthetic use and physiologic manipulations can reduce neurologic injury and assure safe and effective surgical care when cerebral hypoperfusion is a real and significant risk.