Practical neurology
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Practical neurology · Jun 2013
ReviewWhen the going gets tough: how to select patients with Parkinson's disease for advanced therapies.
Levodopa-induced motor complications of Parkinson's disease, including motor fluctuations and dyskinesias, become increasingly frequent as the disease progresses, and are often disabling. Oral and transdermal therapies have limited efficacy in controlling these problems. Advanced device-aided therapies, including continuous infusion of apomorphine, deep brain stimulation and levodopa-carbidopa intestinal gel can all ameliorate these complications. This review summarises the principles of each of these therapies, their modes of action, efficacy and adverse effects, and gives advice on timely identification of suitable patients and how to decide on the most appropriate therapy for a given patient.
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Diagnosing stroke is not always straightforward. Stroke mimics such as Todd's paresis or hemiplegic migraine account for between a fifth and a quarter of suspected strokes (depending on the setting in which they are assessed). Stroke chameleons can arise when the tempo of symptom onset is not apoplectic or if the loss of function is not clearly consistent with a deficit within an arterial territory. Thrombolysis and secondary prevention have much to offer patients with stroke chameleons, though those with stroke mimics may be harmed by these treatments and have more to gain from other therapies.
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Practical neurology · Jun 2010
ReviewAdvance planning in end-of-life care: legal and ethical considerations for neurologists.
Neurological illnesses can leave patients unable to make legally valid decisions about their medical treatment. However, this loss of decision making capacity can often be predicted in advance. The law in the UK now enables patients to make legally binding arrangements to either refuse specific treatments in advance or to appoint others to make decisions on their behalf. This article discusses the mechanics of advance planning under UK law and the role of the neurologist in helping patients to plan ahead.
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Intravenous thrombolysis significantly improves the chance of independent recovery from ischaemic stroke but its benefit is strongly time dependent: present evidence supports effectiveness when delivered up to 4.5 h after symptom onset but the chance of recovery is twice as great when it is given within 90 min compared with 3-4.5 h. Delivery of treatment to a high proportion of patients is possible but requires clinicians to optimise systems for patient transfer, clinical and radiological assessment. ⋯ Most acute stroke teams cross traditional medical disciplines. Thrombolysis should ideally be delivered within an integrated service that seamlessly includes acute stroke unit care and rehabilitation.
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Practical neurology · Aug 2009
ReviewPrevention and treatment of medical and neurological complications in patients with aneurysmal subarachnoid haemorrhage.
Treatment of patients with aneurysmal subarachnoid haemorrhage not only involves securing the aneurysm by endovascular coiling or surgical clipping but also prevention and treatment of the medical and neurological complications of the bleed. These acutely ill patients should be looked after in specialised centres by a multidisciplinary team that is available 24 h a day, 7 days a week. ⋯ For patients who develop delayed ischaemia, there is no evidence that hypervolaemia, haemodilution, hypertension, balloon angioplasty or intra-arterial vasodilating agents improve outcome. Lumbar puncture is a safe and reasonably effective way of treating those forms of acute hydrocephalus that are not caused by intraventricular obstruction.