Handbook of clinical neurology
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The cerebrospinal fluid (CSF) is a bodily fluid, which is both easily accessible and the most proximate to the pathological alterations of multiple sclerosis (MS). Consequently, the analysis of this fluid provides an important window into the pathological underpinnings of this disease. For example, for years, it has been known that the CSF of MS patients contains oligoclonal gamma immunoglobulins (IgG), which are synthesized within the central nervous system and presumably relate to the immune dysfunction, which is characteristically found in MS. ⋯ Thus, patients without a definite diagnosis who have CSF IgG bands are significantly more likely to develop definite MS compared to those patients without such a banding pattern. Other biological molecules can also be found in the CSF including neurofiliment, myelin basic protein (MBP), glial fibrillary acidic protein (GFAP), tau, neuronal cell adhesion molecule (NCAM), and the growth associated protein (GAP-43). However, the value of measuring these (and other) CSF constituents for both diagnostic and prognostic purposes and for following response to therapy is still to be determined.
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Increased survival of critically ill patients has focused the attention on secondary complications of intensive care unit (ICU) stay, mainly ICU-acquired weakness (ICUAW). ICUAW is relatively common with significant impact on recovery. Prolonging mechanical ventilation and overall hospitalization time, increased mortality, and persistent disability are the main problems associated with ICUAW. ⋯ The approach to the diagnosis and the yield of various techniques (mainly electrophysiological and histological) is discussed. Possible therapeutic interventions of this condition that modify the course of this deleterious situation and lead to better rehabilitation are discussed. The current postulated mechanisms associated with ICUAW (mainly the more frequent critical illness neuropathy and myopathy) are reviewed.
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Posterior reversible encephalopathy syndrome (PRES) is a recently proposed cliniconeuroradiologic entity with several well-known causes, such as hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressive drugs, as well as some causes more recently described. PRES is characterized by neuroimaging findings of reversible vasogenic subcortical edema without infarction. The pathogenesis is incompletely understood. ⋯ The clinical syndrome of PRES typically involves headache, encephalopathy, visual symptoms, and seizures. The clinical presentation is often nonspecific, and therefore the diagnosis of PRES has come to increasingly rely on magnetic resonance imaging (MRI) abnormalities consistent with PRES with documented recovery clinically and on repeated neuroimaging. The diagnosis has important therapeutic and prognostic implications because the reversibility of the clinical and radiologic abnormalities is contingent on the prompt control of blood pressure and/or discontinuing the offending drug.
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Narrowing of the spinal canal or foramina is a common finding in spine imaging of the elderly. Only when symptoms of neurogenic claudication and/or cervical myelopathy are present is a spinal stenosis diagnosis made, either of the lumbar spine, cervical spine or both (only very rarely is the thoracic spine involved). Epidemiological data suggest an incidence of 1 case per 100 000 for cervical spine stenosis and 5 cases per 100 000 for lumbar spine stenosis. ⋯ Surgical strategy consists mainly of decompression (depending on the anatomical level and type of narrowing: laminectomy, foraminotomy, discectomy, corporectomy) with additional instrumentation should spinal stability and sagittal balance be at risk. For cervical spine stenosis the main objective of surgery is to halt disease progression. There is class 1b evidence that surgery is of benefit for lumbar stenosis at least in the short term.
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Bacterial meningitis is a neurologic emergency. Vaccination against common pathogens has decreased the burden of disease. Early diagnosis and rapid initiation of empiric antimicrobial and adjunctive therapy are vital. ⋯ Dexamethasone therapy has been implemented as adjunctive treatment of adults with pneumococcal meningitis. Adequate and prompt treatment of bacterial meningitis is critical to outcome. In this chapter we review the epidemiology, pathophysiology, and management of bacterial meningitis.