Neurologic clinics
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The medical and surgical management of aneurysmal SAH has changed dramatically in the past few decades. Surgical management emphasizes early triage and repair of the responsible aneurysm. ⋯ The results of these techniques have not been studied in randomized controlled trials; however, several large retrospective analyses reveal a significant decrease in mortality and morbidity with the institution of these measures. Future improvements will continue to develop with increased understanding of cerebral vasospasm and in neurologic monitoring.
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NMS is a rare but fatal syndrome that needs to be considered in the perioperative period. Although many aspects remain unexplored and controversial, with greater awareness of the condition, new concepts are coming into light. Definitive treatment guidelines remain an important issue to be addressed. Efforts have been initiated in that direction and all cases can be reported on a toll-free hotline ( 1-888-667-8367) or online (www.nmsis.org).
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The fourth edition of The Diagnostic and Statistical Manual of Mental Disorders defines delirium as "a reversible state of confusion with a reduced level of consciousness manifest as an inability to focus, sustain or shift attention." Pharmacologic agents are important contributors to delirium in hospitalized elderly patients and those patients in the perioperative state. Delirium is especially problematic in patients who are given multiple agents, including hypnotics and analgesics. With an appropriate history, physical examination, and investigations, the causes of delirium can be categorized and are usually due to drug intoxication, metabolic disorders, infection, cardiac disorders, stroke, trauma, reactions to pain, or isolation.
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The perioperative care of patients who have diseases of the nervous system provides the setting for challenging ethical issues. In the preoperative period, these issues include obtaining informed consent for surgery and its complications, surrogate decision making for the neurologically incapacitated patient, the use of advance directives for medical care, and the temporary suspension of do-not-resuscitate orders during the perioperative period. During postoperative care, ethical issues include establishing and communicating prognosis in patients who are brain damaged, a trial of therapy when prognosis remains uncertain, surrogate consent and refusal of life-sustaining therapy in the neurologically impaired patient, and the management of brain death.
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A careful history and physical examination remain the most important aspects of headache assessment. enabling the neurologist to decide if any further studies are necessary. Only a minority of patients who have headaches have brain tumors; however, recognition of the headaches characteristically associated with tumors is most important. Some locations are more likely to produce headache (eg, a posterior fossa tumor causes headache more often than a supratentorial tumor). ⋯ Imaging of headache patients for tumors, if they have primary headache disorders, such as migraine and typical cluster, generally is not cost effective but is necessary if there are any atypical features. Treatment of headache in patients who have metastatic brain tumors should be aggressive in terms of pain and symptoms control. Treatment of primary CNS tumors is dictated by the kind of neoplasm and site, but control of headache should not be ignored.