Continuum : lifelong learning in neurology
-
Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. ⋯ Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.
-
This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. ⋯ For patients with acute ischemic stroke and a large vessel occlusion in the proximal anterior circulation who can be treated within 6 hours of stroke symptom onset, mechanical thrombectomy with a second-generation stent retriever or a catheter aspiration device should be indicated regardless of whether the patient received treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.
-
The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as "Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief. ⋯ PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.
-
"Double vision" is a commonly encountered concern in neurologic practice; the experience of diplopia is always sudden and is frequently a cause of great apprehension and potential disability for patients. Moreover, while some causes of diplopia are benign, others require immediate recognition, a focused diagnostic evaluation, and appropriate treatment to prevent vision- and life-threatening outcomes. A logical, easy-to-follow approach to the clinical evaluation of patients with diplopia is helpful in ensuring accurate localization, a comprehensive differential diagnosis, and optimal patient care. This article provides a foundation for formulating an approach to the patient with diplopia and includes practical examples of developing the differential diagnosis, effectively using confirmatory examination techniques, determining an appropriate diagnostic strategy, and (where applicable) providing effective treatment. ⋯ Binocular diplopia is most often due to a neurologic cause. The onset of true "double vision" is debilitating for most patients and commonly prompts immediate access to health care services as a consequence of functional impairment and concern for worrisome underlying causes. Although patients may seek initial evaluation through the emergency department or from their primary care/ophthalmic provider, elimination of an ocular cause will not infrequently result in the patient being referred for neurologic consultation. A logical, localization-driven, and evidence-based approach is the most effective way to arrive at the correct diagnosis and provide the best outcome for the patient.
-
Continuum (Minneap Minn) · Dec 2018
Review Case ReportsMultimodality Monitoring in the Neurocritical Care Unit.
This article focuses on the multiple neuromonitoring devices that can be used to collect bedside data in the neurocritical care unit and the methodology to integrate them into a multimodality monitoring system. The article describes how to apply the collected data to appreciate the physiologic changes and develop therapeutic approaches to prevent secondary injury. ⋯ Multimodal monitoring is still in the early stages of development. Research is still needed to establish more advanced monitors with the bioinformatics to identify useful trends from data gathered to predict clinical outcome or prevent secondary brain injury.