Neurologic clinics
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Mechanical ventilation (MV) is fundamental to the resuscitation of brain injured patients, facilitating tissue oxygen delivery, helping to modulate cerebral vascular reactivity, and ensuring protection of the airway. These benefits come at a cost, which includes a significantly increased risk of pneumonia, delirium, and the complications of sedation and of endotracheal intubation. ⋯ MV can also induce alveolar damage in susceptible individuals, yet changes in ventilation designed to limit this damage may not be tolerated in the setting of brain injury. Recent research has begun to clarify key questions regarding the pathophysiology and management of MV in critically ill neurological patients.
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Critical illness neuromyopathy (CINM) is suggested by bilateral diffuse weakness predominant in the proximal part of the limbs after improvement of the acute phase of critical illness. Although muscle and peripheral nerve are often involved in combination, muscle involvement alone is increasingly identified on electrophysiologic investigation, including direct muscle stimulation. CINM frequently involves the respiratory muscles and may result in delayed weaning and prolonged mechanical ventilation. Besides muscle immobilization and prolonged sepsis-induced multiorgan failure, which are risk factors for CINM, hyperglycemia and use of corticosteroids might have a deleterious effect on the neuromuscular system in critically ill patients, suggesting opportunities for preventive interventions.
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The optimal management of arterial blood pressure in the setting of an acute stroke has not been defined. Many articles have been published on this topic in the past few years, but definitive evidence from clinical trials continues to be lacking. This situation is complicated further because stroke is a heterogeneous disease. ⋯ This article reviews the relationship between arterial blood pressure and the pathophysiology specific to ischemic stroke, primary intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage, elaborating on the concept of ischemic penumbra and the role of cerebral autoregulation. The article also examines the impact of blood pressure and its management on outcome. Finally, an agenda for research in this field is outlined.
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Traumatic brain injury is a common and complex clinical entity that deserves better and continued research on interventions and initial treatment postinjury. Current medical management of traumatic brain injury is articulated on minimizing secondary injury by optimizing cerebral perfusion and oxygenation and preventing or treating nonneurologic morbidity. There are major medical research efforts examining the underlying mechanisms of secondary brain injury, which provides hope for effective therapies in the future. Presently, a number of promising therapeutic modalities are undergoing clinical trials, and as new pharmacologic and medical approaches are introduced, there will be increasing opportunity to treat these patients and improve their neurologic outcomes.
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Meningiomas and schwannomas are the two most common extra-axial intracranial tumors in adults. Since their initial discovery, these often-benign lesions have shared a parallel metamorphosis in their management. The goal of this article is to provide a review of the current literature surrounding the mainstays of therapy for these lesions.