Seminars in neurology
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Seminars in neurology · Mar 2003
Review Case ReportsWarning signs of imminent respiratory failure in neurological patients.
Critically ill neurological patients often need ventilatory assistance. After acute central nervous system insults, the inability to protect the airway and impaired central respiratory drive can only be managed with endotracheal intubation and mechanical ventilation. ⋯ Simple respiratory function tests performed at the bedside should be used to monitor patients with progressive neuromuscular respiratory insufficiency. Noninvasive positive pressure ventilation plays an important role in the management of respiratory failure in patients with neuromuscular respiratory failure, and its indications may be expanded in the future.
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Seminars in neurology · Mar 2003
ReviewPearls, perils, and pitfalls in the use of the electroencephalogram.
Despite advances in neuroimaging techniques over the past three decades that have helped in identifying structural lesions of the central nervous system, electroencephalography (EEG) continues to provide valuable insight into brain function by demonstrating focal or diffuse background abnormalities and epileptiform abnormalities. It is an extremely valuable test in patients suspected of epilepsy and in patients with altered mental status and coma. Patterns in the EEG make it possible to clarify the seizure type; it is indispensable for the diagnosis of nonconvulsive status epilepticus and for separating epileptic from other paroxysmal (nonepileptic) episodes. ⋯ An EEG is most helpful in determining the severity and, hence, the prognosis of cerebral dysfunction. Lastly, EEG is extremely helpful in assessing normal or abnormal brain functioning in a newborn because of the serious limitation in performing an adequate neurologic examination on the neonate who is intubated or paralyzed for ventilatory control. Under such circumstances, the EEG may be the only available tool to detect an encephalopathic process or the occurrence of epileptic seizures.
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Patients who suffer from neuromuscular diseases often have complications from respiratory insufficiencies. Some neuromuscular diseases, for example Landry Guillain-Barré syndrome, may only require temporary tracheal intubation; patients with other neuromuscular diseases, such as amyotrophic lateral sclerosis, may decide with the assistance of their doctor and family to opt for lifelong noninvasive ventilatory support. Other patients may only opt for noninvasive positive pressure ventilation. ⋯ Early respiratory changes in patients with neuromuscular disease are often best detected during sleep. During rapid eye movement sleep, there is a reduction in respiratory drive predisposing to hypopneas and apneas. The majority of neuromuscular patients with respiratory insufficiency may be monitored and treated in the outpatient setting, thus allowing them to remain in their homes.
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Seminars in neurology · Dec 2002
Historical ArticleThe Romberg sign and early instruments for measuring postural sway.
In the first half of the 19th century, European physicians-including Marshall Hall, Moritz Romberg, and Bernardus Brach-described loss of postural control in darkness of patients with severely compromised proprioception. Romberg and Brach emphasized the relationship between this sign and tabes dorsalis. ⋯ Principal contributors included Philadelphia neurologist Silas Weir Mitchell and his trainees Morris Lewis and Guy Hinsdale. The efforts of these neurologists anticipated later physiologic studies and ultimately the development of computerized dynamic platform posturography.
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Seminars in neurology · Dec 2002
Historical ArticleThe history of the development of the cerebellar examination.
The cerebellar examination evolved from observations of experimental lesions made by neurophysiologists and clinical descriptions of patients with trauma to the cerebellum. At the beginning of the 19th century, neurophysiologists such as Luigi Rolando, Marie-Jean-Pierre Flourens, and John Call Dalton, Jr. ablated portions of the cerebellum of a variety of animals and observed staggering gait, clumsiness, and falling from side to side without loss of strength. They concluded that the cerebellum coordinated voluntary movements. ⋯ In 1917, Gordon Holmes reported hypotonia and dysmetria in men wounded by gunshot wounds to their cerebellum. These observations were rapidly included in descriptions of the cerebellar examination in popular contemporaneous textbooks of neurology. Modern observations have demonstrated that the cerebellum influences such cognitive functions such as planning, verbal fluency, abstract reasoning, prosody, and use of correct grammar.