Neurologist
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Chronic pain is one of the most common and challenging medical problems facing our society. The specialty of pain medicine has grown steadily in recent years, largely because of the recognition that multiple factors contribute to chronic pain. ⋯ Research in the last 30 years has developed a variety of alternatives or adjuncts to opiates for chronic pain, including neuroactive medications, counterstimulation methods, and cognitive-behavioral therapies. Pain medicine specialists have provided leadership in the development of the practice, with the application of a wide verity of central and peripheral nerve blocks, sympathetic and neurolytic blocks, intradiscal procedures, neuromodulation techniques, intrathecal infusion systems, and other technical procedures that are firmly linked to a biomedical model of pain.
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This review discusses a variety of causes of stupor and coma and associated electroencephalographic (EEG) findings. These include metabolic disturbances such as hepatic or renal dysfunction, which are often characterized by slowing of background rhythms and triphasic waves. Hypoxia and drug intoxications can produce a number of abnormal EEG patterns such as burst suppression, alpha coma, and spindle coma. ⋯ This entity, nonconvulsive status epilepticus (NCSE), is difficult to diagnose in obtunded/comatose patients, and an EEG is required to verify the diagnosis and to monitor treatment. Several EEG patterns and their interpretation in suspected cases of NCSE such as periodic lateralized epileptiform discharges (PLEDs), bilateral independent periodic lateralized epileptiform discharges (BIPLEDs), generalized periodic epileptiform discharges (GPEDs), and triphasic waves are reviewed. Other entities discussed include the locked-in syndrome, neocortical death, persistent vegetative state, brainstem death, and brain death.
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Cardiac arrest has a high mortality rate. Postresuscitation encephalopathy is commonly associated with significant morbidity. ⋯ The authors discuss the physiology, pathology, and consequences of cardiac arrest to the central nervous system, and the use of various parameters in prognostication. Induced hypothermia is a new therapeutic development.
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Massive cerebral infarcts cause brain edema with midline shifts and impingement on vital structures producing coma and death. The mortality rate is estimated at 80% with standard medical treatment. Surgical decompression with hemicraniectomy has proved to be life saving, but the impact on functional outcomes is largely unknown. The focus of this review is to discuss the treatment options for massive cerebral infarcts. ⋯ Hemicraniectomy is emerging as a promising treatment of patients with massive cerebral infarcts, but only select patients benefit from this procedure. Further information from randomized controlled trials is required to elucidate the best treatment options for this kind of stroke.
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Herpes simplex encephalitis (HSE) still carries a high morbidity and mortality. ⋯ The safety of anticoagulation in HSE has not been raised in the literature previously, and it needs further study.