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(Download PDF) Emergency Neurology What Do I Do Now 2Nd Edition Sara C Lahue Morris Levin Online Ebook All Chapter PDF
(Download PDF) Emergency Neurology What Do I Do Now 2Nd Edition Sara C Lahue Morris Levin Online Ebook All Chapter PDF
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ADVANCE PRAISE FOR EMERGENCY NEUROLOGY, SECOND EDITION
“Now more than ever, hospital neurologists must be nimble and integra-
tive in responding to complex consultations and urgent cases as their scope
of practice continues to expand rapidly. In this Second Edition of Emergency
Neurology, LaHue and Levin offer nuanced yet pragmatic approaches filled
with clinical pearls relevant to trainees and seasoned clinicians alike. This
book will get you into the mindset of a modern neurohospitalist and will
surely improve your practice.”
—Joshua P. Klein, MD, PhD, Vice Chair, Clinical Affairs,
and Chief, Division of Hospital Neurology,
Department of Neurology, Brigham and
Women’s Hospital, Boston, Massachusetts
Lawrence C. Newman, MD
Director of the Headache Division
Professor of Neurology
New York University Langone
New York, New York
Morris Levin, MD
Director of the Headache Center
Professor of Neurology
University of California, San Francisco
San Francisco, California
OT H E R VO L U M E S IN T HE SE RIE S
SECOND EDITION
Sara C. LaHue, MD
Assistant Professor of Clinical Neurology
Department of Neurology
University of California
San Francisco, CA, USA
Morris Levin, MD
Professor
Department of Neurology
University of California
San Francisco, CA, USA
1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2021
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: LaHue, Sara C., author. | Levin, Morris, 1955–author.
Title: Emergency neurology /Sara C. LaHue, Morris Levin.
Other titles: What do I do now?
Description: 2nd edition. | New York, NY : Oxford University Press, [2021] |
Series: What do I do now | Morris Levin’s name appears first on previous edition. |
Includes bibliographical references and index.
Identifiers: LCCN 2020020672 (print) | LCCN 2020020673 (ebook) |
ISBN 9780190064303 (paperback) | ISBN 9780190064327 (epub) |
ISBN 9780190064334 (online)
Subjects: MESH: Central Nervous System Diseases | Emergencies | Case Reports
Classification: LCC RC350.7 (print) | LCC RC350.7 (ebook) | NLM WL 301 |
DDC 616.8/0425—dc23
LC record available at https://lccn.loc.gov/2020020672
LC ebook record available at https://lccn.loc.gov/2020020673
DOI: 10.1093/med/9780190064303.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or
other professional advice. Treatment for the conditions described in this material is highly
dependent on the individual circumstances. And, while this material is designed to offer accurate
information with respect to the subject matter covered and to be current as of the time it was
written, research and knowledge about medical and health issues are constantly evolving and
dose schedules for medications are being revised continually, with new side effects recognized
and accounted for regularly. Readers must therefore always check the product information and
clinical procedures with the most up-to-date published product information and data sheets
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The publisher and the author make no representations or warranties to readers, express or
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Printed by Marquis, Canada
Contents
Preface vii
Acknowledgments ix
4 Syncope 17
6 Thunderclap Headache 29
8 Hospital-Acquired Delirium 41
10 Refractory Vertigo 53
11 Febrile Dystonia 59
12 Myelopathy 65
17 Functional Hemiparesis 97
Index 213
vi Contents
Preface
Diagnostic Dilemmas
1 Neurological Deficits
Following Carotid
Endarterectomy
A 68-year-old man who presented 6 days
ago with transient language difficulty was
found to have high-grade left internal carotid
stenosis and then underwent left carotid
endarterectomy (CAE) 3 days ago. Today he
awoke with numbness in his right arm, which
has persisted all morning. He also complains of
a mild generalized headache. His wife called 911,
and you are now seeing him the ER. Vital signs
are normal, HEENT exams are normal, lungs
are clear, and cardiac exam is normal. Neck
is supple, and the endarterectomy incision is
healing well. However, there is a bruit over this
carotid. On neurological exam, his mental state,
cranial nerves, strength, and coordination are all
intact, but there does seem to be numbness over
the entire right arm. CT scan without contrast is
normal.
3
V irtually every clinician treating adults knows that carotid endarterec-
tomy (CEA) has been proven effective for treatment of symptomatic
carotid stenosis. Fewer, however, have seen complications and feel com-
fortable dealing with them. It turns out that perioperative mortality can
be as high as 3%, even at experienced centers. All of the usual potential
postsurgical adverse consequences can occur in these patients. Wound de-
hiscence and infection are very rare. The most common adverse sequelae
include myocardial infarction, transient ischemic attack (TIA)/ stroke,
hyperperfusion syndrome (HPS), neck region nerve injury, and parotitis.
Stroke in the perioperative period can result from a number of contributing
causes including platelet aggregation and thrombosis formation, plaque
emboli, carotid dissection, and relatively low cerebral arterial perfusion
pressure. The etiology of TIA or stroke must be assessed in order to choose
the appropriate treatment.
After symptoms that could relate to carotid disease develop, the first
step—and one which must be done quickly—is to rule out intracranial
hemorrhage with head CT scan and then, if negative, to get a reliable visu-
alization of the carotid artery over its cervical and intracranial course. This is
best done via intraarterial angiography to detect flow-limiting dissection or
thrombosis. CT angiography is often quicker and nearly as useful. If either
is found, anti-coagulation had traditionally been the treatment of choice.
High-quality duplex ultrasound evaluation can be helpful to confirm good
flow through the proximal carotid and is used as a first step by some teams.
Some surgeons favor surgical re-exploration if complications happen very
early, with percutaneous carotid angioplasty with direct stenting. Many case
reports document remission of neurological symptoms if stenting is done
quickly, and several case series comparing stenting to surgical re-exploration
attest to this.
Intraarterial thrombolytic therapy, in highly selected cases, may be
another treatment option in patients with a postoperative thrombotic
stroke suggested by arteriography. The rationale for the administration of
tissue-type plasminogen activator (tPA) for these patients is based on its
proven success in acute stroke, but there is no clear evidence to support
its use here.
Further Reading
Fahoum F, Drory V, Issakov J, Neufeld MY. Neurosarcoidosis presenting as Guillain-
Barre-like syndrome: a case report and review of the literature. J Clin Neuromusc
Dis. 2009;11:35–43.
Krishnan AV, Lin CS, Reddel SW, Mcgrath R, Kiernan MC. Conduction block and
impaired axonal function in tick paralysis. Muscle & Nerve. 2009;40:358–362.
Wijdicks EF, Klein CJ. Guillain-Barre syndrome. Mayo Clinic Proc. 2017;92:467–479.