CONTINUUM Lifelong Learning in Neurology最新文献

Objective: This article discusses potential pitfalls when consulting on patients who develop neurologic symptoms in the context of systemic disease and describes strategies to avoid diagnostic errors in this context.

Latest developments: Cognitive biases that shape clinical reasoning have been identified and studied. Improving clinician awareness of cognitive biases can improve clinical reasoning and reduce the risk of diagnostic errors.

Essential points: Neurologists consulting on patients with systemic disease should be aware of particular cognitive biases that can lead to misdiagnosis in this context, such as overapplication of Occam's razor, overly narrow framing of a case because of the specific consult question, oversimplification of the case if the consult question is posed as a "curbside" consult, failure to consider less common diagnoses when the signal-to-noise ratio is typically low for the consult question and context, and overlooking potential diagnoses because of the location in which the patient presents within the hospital.

Objective: This article reviews the clinical manifestations and treatment of the neurologic manifestations of renal and electrolyte disorders.

Latest developments: Osmotic demyelination caused by rapid correction of hyponatremia is now considered exceptionally rare, with studies calling into question current protocols that emphasize slow correction of hyponatremia. Patients with acute renal failure and encephalopathy may have posterior encephalopathy syndrome rather than uremic encephalopathy. Cefepime neurotoxicity in patients with renal failure is increasingly recognized.

Essential points: Electrolyte disorders and uremia usually result in reversible cerebral dysfunction leading to encephalopathy, seizures, and muscle weakness. Hyponatremia is the only electrolyte abnormality associated with irreversible brain injury. Neuroimaging should be considered in patients with acute renal failure and encephalopathy to evaluate for posterior encephalopathy syndrome or subdural hematoma.

Objective: This article provides readers with a foundational approach to the diagnosis and treatment of neurologic syndromes that occur in patients with rheumatologic diseases.

Latest developments: Neuroimaging findings such as the central vein sign on MRI to distinguish the white matter lesions of multiple sclerosis from those of systemic lupus erythematosus (SLE), the trident sign on axial postcontrast spine MRI in patients with sarcoid myelopathy, and vessel wall imaging to differentiate central nervous system vasculitis from vasculopathy, can improve diagnostic precision in patients with neurorheumatologic disorders. Treatment of neurologic complications of rheumatologic disease is guided largely by case series but increasingly incorporates targeted therapies such as infliximab for neurosarcoidosis and neuro-Behçet syndrome.

Essential points: Systemic rheumatologic diseases can cause diverse neurologic symptoms that can be causally related, treatment induced, or comorbid but unrelated. Diagnosis relies on clinical criteria, serology, imaging, and, if these are unrevealing or inconclusive, tissue biopsy.

Objective: This article discusses the diagnosis and treatment of cancer-related neurologic complications including (1) diagnosis and management of brain, spinal, and leptomeningeal metastases; (2) toxicities of conventional cytotoxic, biologic, and targeted therapies with a focus on immunotherapies (immune checkpoint inhibitors and chimeric antigen receptor [CAR] T-cell therapy); (3) paraneoplastic syndromes; and (4) acute and long-term sequelae, including seizures, stroke, neuropathy, and long-term effects of young adult and childhood cancer treatment.

Latest developments: Brain metastases can differ genetically from the primary neoplasm, with some responding to systemic rather than local therapies. Increasing use of immune checkpoint inhibitors has increased the incidence of immune-mediated neurologic complications, including paraneoplastic neurologic syndromes. CAR T-cell therapy, initially developed for leukemia and lymphoma, is being applied to an increasing range of cancers and can cause complications such as cytokine release syndrome and immune effector cell-associated neurologic syndrome, for which specific therapeutic protocols are available.

Essential points: Prompt recognition of direct and indirect neurologic complications of systemic cancers and their evolving treatments is essential to maximize favorable outcomes. Neurologists should be familiar with common and rare neurologic toxicities of conventional chemotherapy, immune checkpoint inhibitors, and CAR T-cell therapy.

Objective: This article reviews the epidemiology, clinical presentation, diagnosis, and management of neurologic complications associated with hematologic disorders.

Latest developments: Hematologic disorders may manifest with cerebrovascular and neuromuscular complications due to thrombotic, hemorrhagic, or immune-mediated mechanisms. Advances in screening, targeted therapies, and interdisciplinary care have improved outcomes for conditions such as sickle cell disease, myeloproliferative neoplasms, thrombotic microangiopathies, antiphospholipid antibody syndrome, and plasma cell dyscrasias.

Essential points: Neurologic complications of hematologic disorders range from cerebrovascular disease to peripheral neuropathy. Early recognition and appropriate management in collaboration with a hematologist are essential to reduce morbidity and mortality.

Objective: This article provides an overview of common neurologic complications of critical illness, with attention to advances in pathophysiology, neuromonitoring, and treatment.

Latest developments: There have been advances in screening tools for delirium and evolving consensus for its pharmacologic and nonpharmacologic treatments. Effects of altered cerebral autoregulation and options for its neuromonitoring in patients with organ-specific encephalopathy are developing areas of research. There is increased understanding of the underlying pathophysiology of septic encephalopathy and critical illness-associated diaphragm weakness.

Essential points: The neurologic complications of critical illness can be unique to the processes underlying the critical illness and can persist as independent disease states even after resolution of the inciting critical illness. Acquired neurologic conditions in patients who have critical illness may be organized into those associated with procedural complications, end organ dysfunction, and prolonged critical illness.