Curr Treat Option Ne
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Clinical presentation, neurologic condition, and imaging findings are the key components in establishing a treatment plan for acute SDH. Location and size of the SDH and presence of midline shift can rapidly be determined by computed tomography of the head. Immediate laboratory work up must include PT, PTT, INR, and platelet count. ⋯ For an acute SDH, evacuation by craniotomy or craniectomy is preferred over burr holes based on available data. Postoperative care includes monitoring of resolution of pneumocephalus, mobilization and drain removal, and monitoring for signs of SDH reaccumulation. Medical considerations include seizure prophylaxis and management as well as management and resumption of antithrombotic and anticoagulant medication.
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Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. ⋯ Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.
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Varicella zoster virus (VZV) is an exclusively human neurotropic alphaherpesvirus. Primary infection causes varicella (chickenpox), after which virus becomes latent in ganglionic neurons along the entire neuraxis. With advancing age or immunosuppression, cell-mediated immunity to VZV declines and virus reactivates to cause zoster (shingles), which can occur anywhere on the body. ⋯ Immunocompromised patients require intravenous acyclovir. First-line treatments for post-herpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, and topical lidocaine patches. VZV vasculopathy, meningoencephalitis, and myelitis are all treated with intravenous acyclovir.
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Neurosarcoidosis can involve either the central nervous system (CNS), the peripheral nervous system (PNS), or both. The clinical manifestations are varied and include cranial neuropathy, aseptic meningitis, hydrocephalus, headache, seizure, neuropsychiatric symptoms, neuroendocrine dysfunction, myelopathy, and peripheral neuropathy. Neurologic problems that develop in sarcoidosis patients should not be assumed to represent neurosarcoidosis, as they are often attributable to another cause. ⋯ Cyclophosphamide is also used for refractory neurosarcoidosis patients, but, because of the drug's significant toxicity, it is usually reserved for severe cases that have failed oral therapies when tumor necrosis factor alpha antagonists cannot be obtained. In addition to anti-granulomatous therapy, treatment is frequently required for neurosarcoidosis-associated conditions, such as epilepsy and neuroendocrine dysfunction. Surgical intervention is indicated for life threatening complications such as hydrocephalus, steroid-refractory spinal cord compression, or mass lesions causing increased intracranial pressure.
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The problem of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) management remains unsolved. Despite a myriad of therapeutic trials, no convincingly effective remedy for SUNCT and SUNA is available at present. Based on open-label communications, some patients seemed to benefit from some pharmacologic, interventional, or invasive procedures. ⋯ Invasive therapy with interventions directed to the first division of the trigeminal nerve or Gasserian ganglion, with local anesthetics or alcohol, radiofrequency thermocoagulation, microvascular decompression, and gamma-knife neurosurgery, have been tried in the treatment of refractory SUNCT. Some patients seemed to benefit from such interventions, but one should still have a critical attitude to these claims since no convincing results have been obtained as yet. The few SUNCT patients who underwent deep brain hypothalamic stimulation obtained a substantial and persistent relief.