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276 Walsh & Hoyt: Clinical Manifestations According to SiteSteven A. Newman, M.D., University of Virginia School of MedicineThe clinical presentation ofan aneurysm is related to its location. In the section that follows, we discuss the clinical manifestations of unruptured aneurysms that originate from the carotid and vertebrobasilar arterial systems. It should be noted that it is often impossible to identify a single ar...
277 Walsh & Hoyt: TumorsSteven A. Newman, M.D., University of Virginia School of MedicineThe most common tumors associated with aneurysms are pituitary adenomas and meningiomas. Most patients with an intracranial tumor and an aneurysm initially develop symptoms and signs from the tumor. Neuroimaging studies may identify an asymptomatic aneurysm. Several mechanisms could account for the ...
278 Walsh & Hoyt: General Clinical ManifestationsSteven A. Newman, M.D., University of Virginia School of MedicineAs recognized by Beadles, aneurysms may cause symptoms in three ways. (a) Large aneurysms can produce symptoms from mass effect, in which case the symptoms depend on the function of the adjacent neural tissue. The frequency of mass effect also depends on the location of the aneurysm. Cavernous sinus...
279 Walsh & Hoyt: PathogenesisSteven A. Newman, M.D., University of Virginia School of MedicineThe congenital hypothesis stresses the findings of Eppinger and Forbus, who suggested that developmental defects in the structure of the wall may predispose to aneurysm formation. Late-onset development of aneurysms in familial groups and development of ""mirror"" aneurysms argue for a congenital de...
280 Walsh & Hoyt: Summary of Neuro-Ophthalmologic Signs of Unruptured Intracranial Saccular AneurysmsSteven A. Newman, M.D., University of Virginia School of MedicineNeuro-ophthalmologic signs are among the most important focal neurologic manifestations of unruptured intracranial saccular aneurysms. It must be remembered, however, that aneurysms that become symptomatic because of direct interference with the function of adjacent neural and vascular structures ar...
281 Aneurysms Arising from the Junction of the Internal Carotid and Ophthalmic Arteries (Carotid-Ophthalmic Aneurysms)Steven A. Newman, M.D., University of Virginia School of MedicineAneurysms that arise from the portion of the ICA within the cavernous sinus behave differently from aneurysms originating in any other location within the skull.
282 Fibromuscular DysplasiaSteven A. Newman, M.D., University of Virginia School of MedicineFibromuscular dysplasia (FMD) is a disorder of medium diameter arteries.
283 Subarachnoid HemorrhageSteven A. Newman, M.D., University of Virginia School of MedicineThe diagnosis of aneurysmal SAH should be suspected in any patient with the acute onset of headache, change in mentation or a stiff neck.
284 Diagnosis of Subarachnoid HemorrhageSteven A. Newman, M.D., University of Virginia School of MedicineThe diagnosis of aneurysmal SAH should be suspected in any patient with the acute onset of headache, change in mentation or a stiff neck.
285 Aneurysm Arising from the Cavernous Portion of the Internal Carotid Artery (Intercavernous Aneurysms)Steven A. Newman, M.D., University of Virginia School of MedicineAneurysms that arise from the portion of the ICA within the cavernous sinus behave differently from aneurysms originating in any other location within the skull.
286 Fusiform Aneurysms (Arterial Exctasia, Dolichoectasia)Steven A. Newman, M.D., University of Virginia School of MedicineLarge arteries of the carotid and vertebrobasilar systems may occasionally become enlarged and tortuous.
287 AneurysmsSteven A. Newman, M.D., University of Virginia School of MedicineThe first description of aneurysmal dilation of the cerebral vessels dates to the mid-18th century.
288 Walsh & Hoyt: Pseudotumor Cerebri: ComplicationsDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternThe natural history of PTC is unknown. In some cases it is a self-limited condition; in others, the ICP remains elevated for many years, even if systemic and visual symptoms resolve.
289 Walsh & Hoyt: Papilledema: TerminologyDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternPapilledema is one of the most alarming signs in clinical medicine. Papilledema specifically refers to swelling of the optic disc resulting from increased intracranial pressure (ICP). The term papilledema is often loosely applied to any type of swelling of the optic disc regardless of the etiology. ...
290 Walsh & Hoyt: Papilledema: DiagnosisDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternThe most important method of diagnosing papilledema is careful ophthalmoscopic examination, assessing the features described above. An examination that includes red-free ophthalmoscopy and slit lamp biomicroscopy with a handheld or contact lens is usually sufficient to determine whether papilledema ...
291 Walsh & Hoyt: Unilateral or Asymmetric PapilledemaDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternPapilledema is usually bilateral and relatively symmetric in the two eyes. In some instances, it is strictly unilateral or at least much more pronounced in one eye than in the other. Some patients may have had preexisting atrophy before the development of increased ICP (the pseudo-Foster Kennedy syn...
292 Walsh & Hoyt: Pseudotumor Cerebri: EpidemiologyDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternPTC affects infants, children and young adults but rarely has onset over age 45 years. The idiopathic form (IIH) is typically a disorder of obese females of childbearing age. The incidence of PTC varies throughout the world. Two studies in the United States estimated the incidence at approximately 0...
293 Walsh & Hoyt: Papilledema: Symptoms and SignsDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternBoth nonvisual and visual symptoms occur in patients with papilledema. As a general rule, the nonvisual symptoms are more severe and bothersome to the patient, although visual symptoms can be both distressing and indicative of impending permanent visual dysfunction.
294 Walsh & Hoyt: Papilledema: PathogenesisDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternAny unifying mechanism for papilledema must account for (a) transient unilateral or bilateral visual obscurations; (b) edema localized to the optic nerve head; (c) flattening of the posterior sclera as demonstrated by neuroimaging techniques, and (d) venous distension and cessation of venous pulsati...
295 Walsh & Hoyt: Secondary CausesDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternIIH is a diagnosis of exclusion that occurs primarily in young obese women, and occasionally obese men, with no evidence of any underlying disease. The PTC syndrome may be associated with a number of different conditions. The suspicion of a secondary cause is heightened in prepubertal children, men,...
296 Walsh & Hoyt: Pseudotumor Cerebri: DiagnosisDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternThe diagnostic criteria for IIH are: (a) symptoms and signs solely attributable to increased ICP; (b) elevated CSF pressure; (c) normal CSF composition; (d) normal neuroimaging studies; and (e) no other etiology of intracranial hypertension identified. Each of these criteria are discussed below.
297 Walsh & Hoyt: Papilledema: General ConsiderationsDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternThe craniospinal cavity is an almost rigid bony enclosure completely filled by tissue, CSF, and circulating blood. Within this enclosure, CSF is constantly produced at the rate 500 ml/day, or 0.35 ml/minute. Almost all of the production is by the choroid plexus within the lateral ventricles, althoug...
298 Walsh & Hoyt: Chronic PapilledemaDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternWhen papilledema persists, hemorrhages and exudates slowly resolve, and the disc develops a rounded appearance. The central cup, which may be retained in the acute phase of papilledema, ultimately becomes obliterated. Over a period of months, the initial disc hyperemia changes to a milky gray appear...
299 Walsh & Hoyt: Pseudotumor Cerebri: MonitoringDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternSince the major morbidities of PTC are visual loss and headaches, a team approach to management is necessary. The tempo of visual loss in patients with PTC may be rapid or slowly progressive. Most visual defects associated with papilledema are reversible if ICP is lowered before there is severe visu...
300 Walsh & Hoyt: Pseudotumor Cerebri: TreatmentDeborah I. Friedman, MD, MPH, Professor, Neurology & Neurotherapeutics, University of Texas SouthwesternMost patients with PTC will require co-management from more than one physician. A neurologist, ophthalmologist, primary care physician and neurosurgeon may be involved in the patients care. The primary responsibility for coordinating the patients treatment is generally relegated to the neurologist o...
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