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Falls and Drop Attacks

Falls and Drop Attacks—Introduction Falling in childhood is part of growing up and usually medically insignificant, unless a serious childhood illness contributes. With advancing age, the potential for injury and other complications increases, and falling eventually develops into a dangerous burden for the elderly and the neurologically impaired. Quality of life can be severely affected by associated morbidity, immobilization, fear of falling (FOF), and growing dependency.…

Episodic Impairment of Consciousness

Temporary loss of consciousness may be caused by transient impaired cerebral perfusion (the presumed mechanism for syncope), cerebral ischemia, migraine, epileptic seizures, metabolic disturbances, sudden increases in intracranial pressure (ICP), or sleep disorders. These conditions may be difficult to distinguish from anxiety attacks, psychogenic nonepileptic spells (PNESs), panic disorder, and malingering, which should always be considered. Syncope is defined as an abrupt, transient, complete loss of…

Diagnosis of Neurological Disease

Neurological diagnosis is sometimes easy, sometimes quite challenging, and specialized skills are required. If a patient shuffles into the physician’s office, demonstrating a pill-rolling tremor of the hands and loss of facial expression, Parkinson disease comes readily to mind. Although making such a “spot diagnosis” can be very satisfying, it is important to consider that this clinical presentation may have another cause entirely—such as neuroleptic-induced parkinsonism—or…

Care at the End of Life

Neurologic disorders are often progressive, may be incurable, and commonly lead to significant disability. Palliative care is an important aspect of their management and may be required at any stage of the disease process. This chapter focuses on one specific aspect of palliative medicine, namely end-of-life care, which is often inadequate even in advanced societies. With the advent of increasingly sophisticated technology and more powerful pharmacologic…

Dementia and Systemic Disease

Dementia is a common problem among the elderly and is associated with a number of important systemic complications. Epidemiologic studies estimate the prevalence of Alzheimer disease, the most common form of dementia, in the United States to be approximately 3 percent between ages 65 and 74, 17 percent between ages 75 and 84, and 32 percent over age 84, which ensures that nearly every physician will…

Disorders of Consciousness in Systemic Diseases

Consciousness is a complex and elusive concept that has been the subject of extensive thought and speculation by philosophers, theologians, and scientists since antiquity. The fact that consciousness may mean different things depending on the context (philosophy, religion, science) demonstrates the importance that understanding normal and disordered consciousness holds across a wide variety of fields of study. In medicine, disorders of consciousness are pervasive among the…

Neuromuscular Complications of General Medical Disorders

The diagnosis of disorders of the neuromuscular system involves localizing the lesion anatomically and then weighing the validity of specific diagnostic hypotheses. Symmetry and rapidity of the disease process are major diagnostic considerations. Pure motor syndromes localize to the anterior horn cells, neuromuscular junctions, or muscles, though, rarely, neuropathies can also produce pure motor deficits. Combinations of motor and sensory deficits suggest radiculopathy, plexopathy, or neuropathy.…

Headache in General Medical Conditions

Headache disorders are very common, and therefore they often co-exist with one or more significant medical illnesses. This pairing can complicate the diagnosis of both the headache disorder and general medical conditions, while raising a number of treatment conflicts. In patients with multiple complex medical conditions, management decisions can be difficult. However, if the clinician is armed with an understanding of the key features of common…

Movement Disorders Associated With General Medical Diseases

Movement disorders may complicate a variety of general medical diseases. Evaluation of patients with involuntary movements or postures requires a detailed history, including an account of perinatal events, ethnicity, parental consanguinity, psychiatric disorders, past medications, exposure to infectious agents, immunologic status, substance abuse, and exposures to toxins. The age of onset and pattern of progression further direct the evaluation. Clinical examination should be directed at determining…

Seizures and General Medical Disorders

Seizures commonly arise in persons without epilepsy as a symptom of various general medical disorders, and they can have important implications for the treatment and prognosis of the primary disease. The occurrence and management of seizures in common medical conditions are discussed in this chapter. Attention is also directed at certain less common medical diseases in which seizures are a relatively frequent complication, and at the…

Neurologic Complications in Critically Ill Patients

Injury to other organ systems may have a direct or remote effect on the neurologic system. Hepatic, cardiac, pancreatic, and renal dysfunction can directly affect neurologic transmission and function through a variety of mechanisms. This chapter will examine what is currently understood about the immediate and long-term effects of critical illness on both the central and peripheral nervous systems. Methods to examine, prognosticate, and potentially treat…

Neurologic Disorders and Anesthesia

Current rates of anesthetic complications are low regardless of the type of anesthesia (general, regional, or local). Yet among the complications that may occur, those affecting the nervous system are perhaps the most feared ( Table 55-1 ). This chapter reviews anesthetic-related perioperative neurologic problems as well as perioperative complications that are not caused by anesthesia but are often erroneously attributed to it. Considerations regarding the…

Preoperative and Postoperative Care of Patients with Neurologic Disorders

Introduction Perioperative care of the patient with neurologic disease provides practitioners with a number of unique challenges ranging from timing of surgery, administration of medications, and anesthetic choices, to postoperative care. This chapter focuses on common neurologic disorders and the perioperative considerations that accompany them. Movement Disorders Parkinson disease remains a common neurodegenerative disease particularly among persons over age 70 years. Therefore, thousands of parkinsonian patients…

Neurologic Complications of Imaging Procedures

Neurologic complications of imaging examinations and image-guided procedures are varied and largely related to excessive or inappropriate use of ionizing radiation-based imaging studies, local complications of the invasive procedure, complications related to exposure to high magnetic fields, or complications arising from the use of intravenous contrast agents. This chapter provides a summary of neurologic complications related to those imaging procedures that are commonly performed in modern…

Functional (Psychogenic) Neurologic Disorders

Introduction A functional neurologic disorder (FND) is any type of neurologic disorder that arises from dysfunction of the brain when normal function is possible. The name of this disorder has changed over the years. Previously called hysteria and conversion disorder , it then became psychogenic neurologic disorder , and only in recent years has the terminology changed to functional neurologic disorder . The change is due…

Neurologic Aspects of Sleep Medicine

Sleep disorders commonly occur in patients who present to neurologists. At times, symptoms are obvious, such as insomnia or excessive daytime sleepiness (EDS). However, some patients have serious sleep disorders, such as sleep apnea, that are often not readily apparent to the patient or physician and can exacerbate a neurologic disorder. Established links exist between sleep apnea and stroke, epilepsy, and migraine, between certain sleep behavior…

Connective Tissue Diseases, Vasculitis, and the Nervous System

The systemic inflammatory disorders discussed in this chapter can manifest with diverse neurologic syndromes due to central, peripheral, and autonomic nervous system involvement. These presentations can be in isolation or coincident, sequential or simultaneous. Patients can also develop neurologic syndromes secondary to the treatment of systemic inflammatory disease. Here, we discuss the connective tissue disorders and vasculitides that commonly have neurologic manifestations as well as differential…

Sarcoidosis of the Nervous System

Sarcoidosis was first described in 1877 by Sir Jonathan Hutchinson as a disease of the skin. At the turn of the century, Caesar Boeck termed the disease multiple benign sarkoid , because of its histologic similarity to sarcoma, and from this is derived the modern term sarcoidosis. Boeck also demonstrated the unifying pathologic feature of sarcoidosis as epithelioid cell granulomas that could involve different organs. Sarcoidosis…

Neurologic Complications of Vaccination

Infectious diseases have historically been the major cause of human morbidity and mortality, and vaccinations have added immeasurably to human health by preventing them. The benefits of vaccinations have not come without some costs, and rare adverse effects of vaccines occur. Many important adverse events are neurologic, and these are discussed in this chapter. The US Centers for Disease Control and Prevention (CDC) regularly update and…

Chronic Meningitis

Chronic meningitis is a challenging condition in which the etiology often eludes the treating physician. There are a multitude of potential causes that span several specialties, sometimes leading to input from colleagues in neurology, internal medicine, infectious diseases, rheumatology, immunology, and oncology ( Table 47-1 ). A meticulous approach to the history, exam, and ordering of correct investigations may help lead to the diagnosis and prompt…