Practical neurology
-
Practical neurology · Jun 2010
ReviewAdvance planning in end-of-life care: legal and ethical considerations for neurologists.
Neurological illnesses can leave patients unable to make legally valid decisions about their medical treatment. However, this loss of decision making capacity can often be predicted in advance. The law in the UK now enables patients to make legally binding arrangements to either refuse specific treatments in advance or to appoint others to make decisions on their behalf. This article discusses the mechanics of advance planning under UK law and the role of the neurologist in helping patients to plan ahead.
-
Intravenous thrombolysis significantly improves the chance of independent recovery from ischaemic stroke but its benefit is strongly time dependent: present evidence supports effectiveness when delivered up to 4.5 h after symptom onset but the chance of recovery is twice as great when it is given within 90 min compared with 3-4.5 h. Delivery of treatment to a high proportion of patients is possible but requires clinicians to optimise systems for patient transfer, clinical and radiological assessment. ⋯ Most acute stroke teams cross traditional medical disciplines. Thrombolysis should ideally be delivered within an integrated service that seamlessly includes acute stroke unit care and rehabilitation.
-
An unusual case is presented of a tourist who developed fatal cerebral air embolism, pneumomediastinum and pneumopericardium while ascending from low altitude to Europe's highest railway station. Presumably the air embolism originated from rupture of the unsuspected bronchogenic cyst as a result of pressure changes during the ascent. ⋯ People with known bronchogenic cysts should be informed about the risk of cerebral air embolism and surgical removal should be considered. Cerebral air embolism is a rare cause of coma and stroke in all activities with rapid air pressure changes, including alpine tourism, as our unfortunate tourist illustrates.