Practical neurology
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Practical neurology · Feb 2016
ReviewNeoplastic cauda equina syndrome: a neuroimaging-based review.
Cauda equina syndrome refers to dysfunction of the cauda equina, the collection of ventral and dorsal lumbar, sacral and coccygeal nerve roots that surround the filum terminale. This most commonly occurs as a result of compression by a herniated lumbosacral disc. However, the syndrome may also complicate metastatic cancer or a primary neoplasm within or infiltrating the spinal canal. ⋯ Here we review the diverse neoplastic causes affecting the cauda equina nerve roots from a neuroimaging-based perspective. We divide them by location into intramedullary neoplasms at the conus (such as astrocytoma), intradural-extramedullary neoplasms (such as schwannoma and leptomeningeal metastases) and extradural neoplasms (such as spinal metastases from systemic neoplasms). We also discuss the clinical features associated with cauda equina tumours, with special focus on cauda equina syndrome.
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Practical neurology · Oct 2015
ReviewSomatosensory evoked potentials aid prediction after hypoxic-ischaemic brain injury.
Cardiopulmonary resuscitation, basic life support and early defibrillation are leading to more survivors of out-of-hospital cardiac arrest reaching hospital. Once stabilised on an intensive care unit, it can be difficult to predict the neurological outcome using clinical criteria alone, particularly with modern management using sedation, neuromuscular blockade and hypothermia. If we are to prevent ongoing futile life support, it is important to try to identify the majority of patients who, despite best efforts, will not make a meaningful recovery. Somatosensory evoked potentials are widely available electrophysiological tests that can provide an objective biomarker of a poor neurological outcome and assist in predicting the prognosis.
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Practical neurology · Aug 2015
ReviewAntithrombotic treatment and intracerebral haemorrhage: between Scylla and Charybdis.
In patients who have intracerebral haemorrhage while on antithrombotic treatment, there is no evidence from randomised clinical trials to support decisions with regard to antithrombotic medication. In the acute phase, we advise stopping all antithrombotic treatment with rapid reversal of antithrombotic effects of oral anticoagulants. After the acute phase, we discourage restarting oral anticoagulants in patients with a lobar haematoma caused by cerebral amyloid angiopathy because of the high risk of recurrent bleeding. ⋯ In patients with non-lobar intracerebral haemorrhage, we suggest considering restarting optimal antithrombotic treatment. This includes treatment with oral anticoagulants for patients with atrial fibrillation and/or mechanical valve prosthesis. After intracerebral haemorrhage during oral anticoagulant therapy in patients with atrial fibrillation, direct anticoagulants may be better than vitamin K antagonists, but we await confirmation of this from ongoing trials.
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It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of 'concussed' individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. ⋯ Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.