Articles: patients.
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J. Thromb. Thrombolysis · Jan 1995
Thrombolysis in Acute Myocardial Infarction Complicated by Cardiogenic Shock.
The adverse impact of the development of cardiogenic shock in the setting of acute myocardial infarction was first described by Killip and Kimball in 1967. While the in-hospital mortality rate in patients with myocardial infarction and no evidence of heart failure was only 6%, the mortality rate in those patients who developed cardiogenic shock was 81%. Despite advances in cardiovascular care and therapy since that initial report, including universal institution of cardiac care units, advances in hemodynamic monitoring, new inotropic and vasodilating agents, and even increasing utilization of thrombolytic therapy, the mortality from acute myocardial infarction, when complicated by cardiogenic shock, remains disturbingly high, and cardiogenic shock remains the leading cause of death of hospitalized patients following acute myocardial infarction. ⋯ These low perfusion rates may, in part, be explained by decreased coronary blood flow and perfusion pressure in patients with left ventricular pump failure. Although promising as adjunctive therapy, it is unclear whether institution of balloon counterpulsation has any long-term benefit in patients with cardiogenic shock treated with thrombolytic therapy. Whether other or additional interventions, such as coronary angioplasty and coronary artery bypass graft (CABG), decrease mortality rates in patients with cardiogenic shock remains to be determined.
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Effective treatment of patients with trigeminal neuralgia is often a long and complicated procedure. The symptoms of trigeminal neuralgia are clearly defined in most cases. Sudden and brief episodes of severe and stabbing pain (tic douloureux) occur, with pain usually starting from a trigger point. Recent reports suggest 80-90% suppression of pain with various treatment regimens, which seems to indicate that the diagnosis and successful treatment of the disorder are no longer a major problem. In fact, however, the intense suffering of patients and isolated reports in the literature suggest that there are still considerable diagnostic difficulties. Patients are referred from one specialist to another, in most cases without the necessary interdisciplinary cooperation, and countless interventions and attempts at therapy not only remain unsuccessful, but may cause serious adverse effects. ⋯ Apparently there is a considerable need for more information about the clinical symptoms, cause, diagnosis and therapy of trigeminal neuralgia, especially as the symptoms are often no longer typical because they have become chronic or are the result of previous treatment. This is needed by all specialists involved, including dentists and general practitioners. In patients in whom clinical criteria suggest the diagnosis of trigeminal neuralgia, drug treatment should be initiated immediately in consultation with the neurologist or neurosurgeon. For cases in which drug treatment fails or resistance to the drug develops surgical treatments are available, such as non-destructive microvascular decompression or thermocoagulation of the gasserian ganglion.
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Unfortunately, sharp, severe pain in the area of distribution of the fifth cranial nerve is frequently termed trigeminal neuralgia, and no differentiation is made between typical and atypical neuralgia and other types of facial pain disorders. This can lead to inadequate treatment. ⋯ The process of differential diagnosis is critical in trigeminal neuralgia, because an incorrent or missed diagnosis is one of the most frequent causes of treatment failure. As idiopathic trigeminal neuralgia, craniomandibular disorders or the cervical spine syndrome can involve similar symptoms and response to the use of medication, close interdisciplinary cooperation in the process of diagnosis is recommended.
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J Stroke Cerebrovasc Dis · Jan 1995
Transcranial Doppler signals during cerebral angiography and cardiac catheterization.
Cerebral angiography is associated with a 0.45-4% risk of neurological complications and a less than 1% risk of permanent neurological deficit. Recently, air embolism has been implicated as a major cause of these complications. Cardiac catheterization is associated with a neurological complication rate of less than 1%; the predominant mechanism appears to be embolic. ⋯ No spontaneous emboli were seen. None of our 42 patients developed any type of neurological symptoms during or after the procedure. These high-intensity signatures do not represent air embolism exclusively; rather, they are likely a combination of turbulence in the bloodstream created during rapid injection, air emboli, and, perhaps, echogenicity of the contrast medium.
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Unilateral oval pupil has numerous causes, and several pathophysiologic mechanisms have been proposed. Prognosis is nearly universally poor. ⋯ Both patients recovered. The prognosis for comatose patients with unilateral oval pupil is not universally poor.