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In the 26 years since the publication of the third edition of Stupor and Coma spasms right abdomen purchase imuran with a mastercard, several groups of neurologists and neurosurgeons have initiated studies to identify and quantify early clinical spasms right side of stomach order imuran no prescription, neurophysiologic vascular spasms discount 50mg imuran amex, radiologic muscle relaxers not working order discount imuran line, and biochemical indicants that might predict outcome in comatose patients. These studies have identified the etiology of injury, the clinical depth of coma, and the length of time that a patient remains comatose as the most critical factors. The bold black line indicates emergence from the minimally conscious state, defined by reliable functional communication. Several limitations, as discussed below, place stringent demands on physicians to carefully consider all available historical details and the reliability of clinical and laboratory evaluations in their consideration of prognosis for an individual patient. Prospective studies of prognosis in adults and children indicate that within a few hours or days after the onset of coma, neurologic signs and electrophysiologic markers in many patients differentiate, with a high degree of probability, the extremes of no improvement or good recovery. Unfortunately, radiologic and biochemical indicators have generally provided less accurate predictions of outcome, with some exceptions discussed below. Accurate prognostication improves over time, but it is still unclear how early one can make accurate predictions within different diagnostic categories. The first section of this chapter details what we now know about prognosis, emphasizing broad outcome categories and shortterm outcomes rather than outcomes beyond a year or longer, although we recognize that rarely, even severely brain-injured patients may improve after many years (see page 371). We use the scheme in Table 9­1 to assess the reliability of the data presented in this section. The second section addresses mechanisms that may underlie recovery, or lack thereof, from coma. Severe cognitive disabilities can arise from at least two fairly different anatomic injuries: (1) extensive, relatively uniform diffuse axonal injury or hypoxic-ischemic damage causing widespread neuronal death and (2) focal cerebral injuries causing functional al- teration of integrative systems in the upper brainstem and thalamus. New studies suggest that physiologic correlates of brain function in some severely disabled patients with relatively intact cerebral structures may ultimately lead to identification of residual cerebral capacities. The third section addresses important ethical considerations in dealing with comatose patients and their families and caregivers. For the two most carefully studied etiologies of coma, traumatic brain injury and cardiopulmonary arrest, mortality ranges from 40% to 50% and 54% to 88%,2 respectively. These statistics have actually improved since the last edition of Stupor and Coma, because of better acute management both in the field and in intensive care. Beyond mortality statistics, very few studies of prognosis in coma have looked at large numbers of patients for careful evaluation of outcomes other than survival or death. These indicate that patients comatose from traumatic brain injury have a significantly better prognosis than patients with anoxic injuries. For example, of 1,000 trauma patients in coma for at least 6 hours, 39% recovered independent function at 6 months,3 whereas only 16% of 500 patients suffering nontraumatic coma made similar recoveries at 1 year. This section reviews efforts to predict outcome from coma for different etiologies. The reader will find that the literature continues to provide little specific information about the kind of outcome enjoyed or suffered by patients. The definitions attempted to identify fairly precisely what was meant by each grade of outcome. Only a small number of outcomes were chosen in the hope that sufficient numbers of patients would fall into each class to allow statistical analysis, but that important differences in medical and social recovery would not be excessively blurred. There still exists a need for further subdivision and consideration of outcomes in the severely disabled group, as discussed below. For example, when using the prognostic data provided below, care should be taken to distinguish indicators of death from those indicating outcomes including severe disability, which remains a very broad category. Where possible, information specific to other etiologies is provided below, but the physician should recognize this general limitation when formulating a prognosis for a comatose patient who has not suffered a traumatic brain injury or cardiac arrest. Consciousness, Mechanisms Underlying Outcomes, and Ethical Considerations 345 a better prognosis than nontraumatic coma, possibly because patients are usually younger and the pathophysiology differs from other types of coma. Recovery after prolonged traumatic coma is well described and, unlike nontraumatic causes, unconsciousness for 1 month does not necessarily preclude significant recovery. Severe head injury causing 6 hours or more of coma still carries a 40% probability of recovering to a level of moderate disability or better. By 6 hours, motor responses no better than abnormal flexor were associated with a mortality of 63%, while abnormal extensor or flaccid responses predicted an 83% mortality. Paradoxically, elderly patients may require a much longer recovery time, so it is risky to predict ultimate recovery early in the course.


  • Lasting damage to the blood vessels or skin with scarring
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Schwann cell nucleus Axon Myelin sheath Nonmyelinated axons Schwann cell cytoplasm Processes of Schwann cells Figure 3-8 Electron micrograph of a transverse section of a myelinated nerve fiber and several nonmyelinated nerve fibers muscle relaxant high buy imuran mastercard. Smooth muscle fiber Figure 3-9 Autonomic neuromuscular junction between a nonmyelinated axon and a smooth muscle fiber muscle relaxer jokes purchase imuran 50 mg otc. Between the individual nerve fibers is a loose spasms meaning in english order imuran 50 mg, delicate connective tissue referred to as the endoneurium spasms rib cage area buy imuran overnight delivery. The connective tissue sheaths serve to support the nerve fibers and their associated blood vessels and lymph vessels. Peripheral nerve fibers can be classified according to their speed of conduction and size (Table 3-2). Each peripheral nerve consists of parallel bundles of nerve fibers, which may be efferent or afferent axons, may be myelinated or nonmyelinated, and are surrounded by connective tissue sheaths. The nerve trunk is surrounded by a dense connective tissue sheath called the epineurium (Fig. Within the sheath are bundles of nerve fibers, each of which is surrounded by a connective tissue sheath called the per- There are 31 pairs of spinal nerves, which leave the spinal cord and pass through intervertebral foramina in the vertebral column. The anterior root consists of bundles of nerve fibers carrying nerve impulses away from the central nervous system; these nerve fibers are called efferent fibers. The posterior root consists of bundles of nerve fibers carrying nerve impulses to the central nervous system; these nerve fibers are called afferent fibers. Because these fibers are concerned with conveying information to the central nervous system, they are called Endoneurium Myelinated nerve fibers Perineurium Figure 3-11 Photomicrograph of a transverse section of a peripheral nerve stained with hematoxylin and eosin (275). The cell bodies of these nerve fibers are situated in a swelling on the posterior root called the posterior root ganglion. Cranial Nerves Endoneurium Perineurium Epineurium There are 12 pairs of cranial nerves (Fig. Some of these nerves are composed entirely of afferent nerve fibers bringing sensations to the brain (olfactory, optic, and vestibulocochlear), others are composed entirely of efferent fibers (oculomotor, trochlear, abducent, accessory, and hypoglossal), while the remainder possess both afferent and efferent fibers (trigeminal, facial, glossopharyngeal, and vagus). Sensory Ganglia the sensory ganglia of the posterior spinal nerve roots and of the trunks of the trigeminal, facial, glossopharyngeal, and vagal cranial nerves have the same structure. The neurons are unipolar, possessing cell bodies that are rounded or oval in shape (Fig. A single nonmyelinated process leaves each cell body and, after a convoluted course, bifurcates at a T junction into peripheral and central branches. The former axon terminates in a series of dendrites in a peripheral sensory ending, and the latter axon enters the central nervous system. The nerve impulse, on reaching the T junction, passes directly from the peripheral axon to the central axon, thus bypassing the nerve cell body. Each nerve cell body is closely surrounded by a layer of flattened cells called capsular cells or satellite cells (Fig. The capsular cells are similar in structure to Schwann Figure 3-12 Structure of a peripheral nerve. Table 3-2 Classification of Nerve Fibers by Speed of Conduction and Size Conduction Velocity (m/s) Fiber Diameter (m) Sensitivity to Local Anesthetics Fiber Type Functions Myelin A Fibers Alpha Beta Gamma Delta 70­120 40­70 10­50 6­30 12­20 5­12 3­6 2­5 B Fibers C Fibers 3­15 0. B: Transverse section of the pons showing the sensory and motor roots of the trigeminal nerve. Capsular cells Cell bodies of neurons Figure 3-14 Photomicrograph of a longitudinal section of a posterior root ganglion of a spinal nerve stained with hematoxylin and eosin (400). Autonomic Ganglia the autonomic ganglia (sympathetic and parasympathetic ganglia) are situated at a distance from the brain and spinal cord. Each ganglion is surrounded by a layer of connective tissue that is continuous with the epineurium and perineurium of the peripheral nerve. The neurons are multipolar and possess cell bodies that are irregular in shape (Fig. The dendrites of the neurons make synaptic connections with the myelinated axons of preganglionic neurons. The axons of the neurons are of small diameter (C fibers) and unmyelinated, and they pass to viscera, blood vessels, and sweat glands. Each nerve cell body is closely surrounded by a layer of flattened cells called capsular cells or satellite cells. The capsular cells,like those of sensory ganglia,are similar in structure to Schwann cells and are continuous with them as they envelop the peripheral and central processes of each neuron. Figure 3-15 Photomicrograph of a longitudinal section of a ganglion of the sympathetic trunk stained with hematoxylin and eosin (300).

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For example spasms 14 year old beagle order genuine imuran on-line, a friend and mentor of ours muscle relaxant in surgeries imuran 50 mg with mastercard, Molly Harrower spasms down legs when upright buy imuran cheap, a professor emeritus at the University of Florida and inventor of the Group Rorschach spasms just before sleep purchase imuran without prescription, was routinely asked in the 1930s to evaluate "organic patients. Currently, neuropsychologists play a smaller role in diagnosing neurologic disorders but an important part in evaluating functional impairment, prognosis, and recovery. In the late 1930s, neuropsychology engaged the interest of only a few neurologists, psychiatrists, and psychologists. Neuropsychology was loosely organized, and no journals reflected a focused interest in this area. But a number of scholars were working on issues that in time made decisively important contributions to the field and shaped neuropsychology as we know it today. The first neuropsychology laboratory in the United States was founded in 1935 by Ward Halstead at the University of Chicago. Halstead worked closely with neurosurgery patients and developed assessment devices that differentiated between patients with and without brain damage (Figure 1. Together with Ralph Reitan, Halstead later developed the popular Halstead-Reitan Neuropsychological Battery, an empirical approach to assessing brain damage (Halstead, 1947; Reitan & Wolfson, 1993). The term neuropsychology itself is of recent origin and was most likely first coined by Sir William Osler in 1913, when he used the word in an inaugural address for a new psychiatric clinic at Johns Hopkins Hospital in Baltimore, Maryland (Bruce, 1985). In 1936, Karl Lashley also used the term when he addressed the Boston Society of Psychiatry and Neurology (Bruce, 1985). Hans-Leukas Teuber (1916­1977) is credited for first using the term in a national forum during a presentation to the American Psychological Association in 1948, during which he described different aspects of brain­behavior relationships in war veterans with penetrating brain wounds (Teuber, 1950). Then, in 1949, Canadian Donald Hebb published his classic, the Organization of Behavior: A Neuropsychological Theory. The study of neuropsychology has drawn information and knowledge from many disciplines, including anatomy, biology, physiology, biophysics, and even philosophy. Thus, many interdisciplinary professionals, including neurologists, neuropsychiatrists, linguists, neuroscientists, speech pathologists, and school psychologists, are interested in the field of brain­behavior relationships and have contributed to its development. Those that did were primarily researchers in what is now considered experimental neuropsychology. Between 1960 and 1990 neuropsychology was characterized by a movement from the laboratory to the clinic and the establishment of distinct neuropsychological organizations. This phase also marked the creation of many scientific journals that focused exclusively on advancing the science of neuropsychology (Table 1. One of his discoveries, which earned him an enduring place in the history of neuropsychology, Table 1. In the 1940s and 1950s, most scientists believed that the left hemisphere dominated the brain, because it plays an important role in the mediation of language. Hйcaen and his coworkers generated an irrefutable mass of evidence that the right, supposedly minor, hemisphere played a crucial role in mediating visuoperceptual and visuoconstructional processes. There he was called on to evaluate hundreds of patients with traumatic brain lesions. Zangwill was also among the first investigators to show that hemispheric specialization for speech in left-handers did not conform to the thenaccepted rule of right hemisphere dominance (Zangwill, 1960). He also contributed significantly to understanding of the nature of neuropsychological deficits associated with unilateral brain disease or injury. In 1958, he joined the staff of the neurologic service of the Boston Veterans Administration Hospital, where he made many significant contributions to neuropsychology. Among his contributions was his proposal that behavioral disturbances are based on the destruction of specific brain pathways that he called disconnections. He presented his idea in his now classic article "Disconnexion Syndromes in Animals and Man" (1965), which was largely responsible for reemphasizing the important role of neuroanatomy in neuropsychology. Based on his faith that anatomy must play a central role for the description and operation of many complex mental functions, Geschwind set out to prove that the dominance of the left hemisphere for speech must have an anatomic basis. He and a young colleague set out to study the morphologic features of 100 brains and determined that, indeed, there was a strong trend toward a larger auditory association cortex in the left hemisphere (Geschwind & Levitsky, 1968).

But will this new technology fulfill what the phrenologists were unable to do muscle relaxant bodybuilding buy 50 mg imuran with visa, that is muscle relaxant overdose treatment discount imuran generic, create a precise functional map of the brain? Many constraints hinder the use of functional imaging in studying the human brain muscle relaxers not working discount imuran 50mg without prescription. For example infantile spasms 2012 purchase imuran 50 mg line, ultimately, the image rendered is not a direct representation of the mechanism involved in the mental activity, but some correlate. But it is doubtful that imaging technology will ever be able to assess a thought or investigate personality. One of the most exciting advances in the imaging of the living brain is the collaboration among different disciplines, including biomedical engineers, psychiatrists, neurologists, neurosurgeons, and neuropsychologists, to define and differentiate between the normal and the malfunctioning brain. Critical Thinking Questions What are the differences among electrical, magnetic, and metabolic technologies in imaging? Why is co-registration, that is, the use of multiple assessments using different technologies, an important advancement in neuropsychology? Will neuropsychology be outdated by the increased use of sophisticated brain imaging technology? This site can be used as a general reference for exploring the latest in brain imaging. How is clinical neuropsychology distinguishable from clinical psychology or from neurology? Overview Jeanne was a passenger on a motorcycle with her husband when at an intersection a car ran a stop sign and hit them. Although her husband received only minor injuries, Jeanne was thrown about 5 feet. However, Jeanne thinks she must have been knocked out, because she does not remember anything until the ambulance arrived. The hospital released Jeanne that day and told her to see her general practitioner if she had any more problems. Jeanne recovered for a week at home, and then went back to her job as a medical records clerk. Before the accident, she was earning As and Bs; but on her first biology test a month after the accident, she received a D. Four months after her injury, after several visits to her general practitioner and a neurologist, neither of whom could find anything medically wrong with her, her practitioner referred her for a neuropsychological evaluation. The request was to evaluate Jeanne to determine whether she had suffered a brain injury as a result of her accident or if her symptoms might be a psychosomatic reaction, that is, related to increased stress in dealing with the accident and the aftermath. Many people who have head injuries or suffer whiplash injuries in car accidents, sports injuries, or falls may have a brief lapse of consciousness. They may or may not go to a doctor or to the hospital, and if they do, they are usually released after a brief observation. Only after going home and trying to resume the normal tasks of working or going to school may someone such as Jeanne feel unable to concentrate or often forget things. The person may have other odd symptoms that he or she does not understand, such as becoming more easily frustrated or just not feeling "herself. General Considerations in Neuropsychological Testing this chapter describes the most frequently used assessment techniques in neuropsychology and outlines the scientific and theoretical principles of neuropsychological measurement. We stress that clinical neuropsychologists use a number of different methods to evaluate and treat individuals with brain dysfunction. Simply put, neuropsychologists are foremost clinical psychologists who have specialized in neuropsychological conceptualizations and methods. For neuropsychologists to understand the individual, they must view psychology as the expression of neuropsychology. Other employment settings for clinical neuropsychologists include community mental health centers/clinics, school systems, military settings, and prisons/correctional facilities. Across all settings, the "average" clinical neuropsychologist devotes 63% of his or her professional time to neuropsychology, has approximately 12 years of experience in practicing neuropsychology, is 45 years of age, and is predominantly male (73%) (Gordon & Zillmer, 1997). In private practice, the role of the neuropsychologist is perhaps the most varied and flexible, but also the most ambiguous, because the amount of time devoted to neuropsychology depends on the type of patient population.

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