Pseudotumor Cerebri (Benign Intracranial Hypertension)[/color] -Headache, orse on straining! -"isual obscurations / diplopia -#e$el o% consciousness may be impaired!

-&ther de%icits depend on cause o% intracranial hypertension or on herniation syndrome! -'(amination re$eals papilledema! causes -! )hrombosis o% the trans$erse $enous sinus as a nonin%ectious complication o% otitis media or chronic mastoiditis, and sagittal sinus thrombosis may lead to a clinically similar picture! ---&ther causes include chronic pulmonary disease, -endocrine disturbances such as hypoparathyroidism or *ddison+s disease, - $itamin * to(icity, and the use o% tetracycline or oral contracepti$es! Cases ha$e also %ollo ed ithdra al o% corticosteroids a%ter long-term use! ,ymptoms and ,igns headache, diplopia, and other $isual disturbances due to papilledema and abducens ner$e dys%unction! '(amination re$eals the papilledema (see %unduscopy) and some enlargement o% the blind spots, but patients other ise loo- ell! Imaging no e$idence o% a space-occupying lesion, and the C) scan sho s small or normal $entricles! ./ $enography is help%ul in screening %or thrombosis o% the intracranial $enous sinuses! 0#umbar puncture con%irms the presence o% intracranial hypertension, but the cerebrospinal %luid is normal! studies help e(clude some o% the other causes mentioned earlier! /1 2ntreated pseudotumor cerebri leads to secondary optic atrophy and permanent $isual loss[/b]! -[b]*ceta3olamide reduces %ormation o% cerebrospinal %luid and can be used to start treatment! - &ral corticosteroids may also be necessary! -&bese patients should be ad$ised to lose eight! - /epeated lumbar puncture to lo er the intracranial pressure by remo$al o% cerebrospinal %luid is e%%ecti$e, but pharmacologic approaches to treatment are no more satis%actory! -)reatment is monitored by chec-ing $isual acuity and $isual %ields, %unduscopic appearance, and pressure o% the cerebrospinal %luid! -I% medical treatment %ails to control the intracranial pressure, surgical placement o% a lumboperitoneal or other shunt4or subtemporal decompression or optic ner$e sheath %enestration4should be underta-en to preser$e $ision! -In addition to the abo$e measures, any speci%ic cause o% pseudotumor cerebri re5uires appropriate treatment!

[color6dar-red].eralgia Paresthetica -)he lateral %emoral cutaneous ner$e, (sensory ner$e %rom the #7 and #8 roots) may be compressed or stretched in obese or diabetic patients and during pregnancy! -)he ner$e usually runs under the outer portion o% the inguinal ligament to reach the thigh, but the ligament sometimes splits to enclose it! Hypere(tension o% the hip or increased lumbar lordosis4such as occurs during pregnancy4leads to ner$e compression by the posterior %ascicle o% the ligament! -Pain, paresthesia, or numbness occurs about the outer aspect o% the thigh, usually unilaterally, and is sometimes relie$ed by sitting! -'(amination sho s no abnormalities e(cept in se$ere cases hen cutaneous sensation is impaired in the a%%ected area! - Hydrocortisone in9ections medial to the anterosuperior iliac spine o%ten relie$e symptoms temporarily, ner$e decompression by transposition may pro$ide more lasting relie% [color6dar-red]*neurysms o% the )horacic *orta[/color][/b] - account %or %e er than :;< o% aortic aneurysms! - .edial degeneration, chronic dissection, $asculitis, and collagen-$ascular disease (.ar%an+s syndrome or 'hlers=>anlos syndrome) are common causes? -syphilis is no a rare cause o% thoracic aneurysm! - )raumatic aneurysms occur at the ligamentum arteriosus 9ust beyond the le%t subcla$ian artery and result %rom shearing in9ury during rapid-deceleration automobile accidents! )horacoabdominal aneurysms are categori3ed by the Cra %ord [b]classi%ication@ )ype I e(tends %rom the le%t subcla$ian artery to the renal arteries, -type II %rom the le%t subcla$ian artery to the iliac bi%urcation, -type III %rom the midthoracic to the in%rarenal region, and type I" %rom the distal thoracic aorta to the in%rarenal region! )he pre$alence o% each type o% thoracoabdominal aneurysm is roughly e5ual, but type I" aneurysms ha$e the lo est operati$e mortality (7=A<) and the lo est ris- o% postoperati$e neurologic de%icits (7=:;<)! Clinical Bindings depend largely on the si3e and position o% the aneurysm and its rate o% gro th! -.ost are asymptomatic and are disco$ered during a diagnostic procedure underta-en %or other reasons ( (-ray)! - ,ome patients complain o% substernal, bac-, or abdominal pain! &thers e(perience dyspnea, stridor, or a brassy cough %rom pressure on the trachea, dysphagia %rom pressure on the esophagus, hoarseness %rom pressure on the le%t recurrent laryngeal ner$e, or necand arm edema %rom e(ternal compression o% the superior $ena ca$a! - *ortic regurgitation due to distortion o% the aortic $al$e annulus may occur ith aneurysms o% the ascending aorta! Imaging -*n aneurysm suspected on chest radiography must be di%%erentiated %rom other anterior

mediastinal masses, including lung neoplasm, thymoma, cyst, and substernal goiter! -C) scan and ./I are the most sensiti$e and accurate means o% imaging thoracic aneurysms! - *ortography may be necessary to assess in$ol$ement o% the arch $essels! )he coronary $essels and the aortic $al$e should also be studied i% aortic root replacement is anticipated! /1 -Control o% hypertension and use o% Beta-bloc-ers may slo aneurysmal gro th! -Indications %or surgical treatment include the presence o% symptoms, rapid e(pansion, or si3e greater than A cm! - )he thoracotomy incision is associated ith a higher ris- o% pulmonary complications and more challenging postoperati$e pain management! Pro(imity to the recurrent laryngeal ner$e, the phrenic ner$e, and the carotid and subcla$ian arteries ma-es in9ury to these structures possible! )he great radicular artery (artery o% *dam-ie ic3) arises %rom an intercostal artery bet een )C and #: and is the dominant artery to the spinal cord

DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD I,&#*)'> ,E,)&#IC HEP'/)'F)I&F/1 o% choice6)HI*GI>' >I2/')IC,! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD ,EFC&P*# 'PI,&>' ithout %ollo ing disorientation(i!e!, not sei3ure) H'*/IFH I.P*I/'.'F) F&/.*# PHE,IC*# '1*.! B*.I#E HI,)&/E &B ,2>>'F C*/>I*C >'*)H >I*HF&,I,6C&FI'FI)*# JK)JP/&#&FH*)I&F ,EF>/&.'/Ier$ell #ange Feilson ,yndrome P*)H&-PHE,6.olecular de%ect in ion channel!,syncope-due to de$elopment od torsade de pointes type o% $entricular tachycardia! /16,E.P)&-Beta-B#&CL'/MP*C'.*L'/ *,E.P)&-Iust Beta-B#&CL'/! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD)'*/IFH CH',) P*IF radiating to bac-!in a patient ho is/has(pregnant,bicuspid aortic $al$e,co-arctation o% aorta,,mar%ans)! Has HIHH BP(hypertenstion )at presentation! Has %eatures o% I,CH'.I* on e-g (due to in$olement o% ostia!) >I*HF&,I,6*&/)IC >',,'C)I&F

F'1) ,)'P IF .*F*H'.'F)6/'>2C' HEP'/)'F)I&F! B',) >I*HF&,)IC )',)6)/*F, ',&PH*H'*# 'CH&C*/>I&H/*.()'') DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD CH/&FIC CCB patient on digo(in,%rusomide,sim$astatin,spironolactone >e$elops /'C2//'F) "'F)/IC2#*/ )*CHEC*/>I*! >I*HF&,I,-6'#'C)/&#E)' I.B*#*FC' IF>2C'> *//HE)H.I* >ue to hypo-alemia induced by %rusemide that leads to digo(in to(icity /16stabili3e pt! Nith *.I&>*/&F'! F'1) ,)'P *B)'/ ,)*BI#IGIFH6.'*,2/' ,'/2. '#'C)/&#2E)' )& C&FBI/. >I*HF&,I,!

CCB(dyspnea,9ugular $enous distrntion,pedal edema,M$e -ussmals sign) C1/-C*/>I&.'H*#E! 'CH&-,E..')/IC*#E 'F#*/H'> "'F)/IC2#*/ N*##)HICLF',,,F&/.*# C*"I)E *F> ,E,)&#IC B2FC)I&FO!,JJ,P'CL#'> *PP'*/*FC'JJ! >I*HF&,I,6/',)/IC)I"' C*/>I&.'H*#E secondary to *.E#&I>&,I,! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD >IPE/I.*>&#' *F> *>'F&,I,F'@-both used in myocardial per%usion scanning to sho areas o% decreased myocardial per%usion! -both are conary "*,&>I#*)&/, ,increase %lo by 8-A times but in C*> already distal segment to obstruction is dilated ,so there is redistribution o% blood occurs to nondiseased areas ith decreased per%usion to deceased areas this is -no n as C&/&F*/E ,)'*# PH'F&.'F&F DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD a patient de$elops P*IF,P*/*',)H',I*,,P*#',C&#> #I.B 8-P days a%ter *F)'/I&/ N*## .I in lo er limb! >iagnosis6'.B&#IG*)I&F B/&. )H/&.B2, &F *F)! N*## &B #'B) "'F)/IC#'! B',) >I*HF&,)IC )',)6*/)I/I&H/*. o% a%%ected limb! /1 &B CH&IC'/F'1) B',) ,)'P *B)'/ >I*HF&,I,6'.B&#'C)&.E 0C#&) in pro(imal arteries '.B&#'C)&.E P/'BB'/'> but i% present in >I,)*# */)'/I',6IF)/* */)'/I*# )H/&.B&#E,I, I, a good alternati$e! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD /1 &B /',)/IC)I"' C*/>I&.E&P*)HE -among all causes

(amyloidosis,hemochromatossiis,sarcoidosis,idiopathic,sclerodermal,!!)o% restr!cardiomypthies only case here there is impro$ement in prognosis is treatement o% H'.&CH/&.*)&,I, ith phlebotomy and s/c despherio(amine3 DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD e(ertional dyspnea,%e$er,anorhe(ia,malaise ,%atigue, eight loss(,E,)'.IC ,E.P)&.,)M.I>->I*,)&#IC .2/.2/ NI)H&2) &P'FIFH ,F*P! 'CH&6.*,, in le%t atrium! >I*HF&,I,6*)/I*# .E1&.*! >>6.,(opening snap present and systemic symptoms unli-ely unless complicated by ,B'F>&C*/>I)I, in hich case blood cultures ill be positi$e .urmur o% atrial my(oma also changes ith position! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD 0*trial %ibrillation in hyperthyroididm is /1 ith P/&P/*F&#&#(because atrial %ib in gra$e is due to increased sensiti$ity o% adrenoreceptors to sympathetic stimuli 0,ame (beta bloc-er) is /1 in pts ith HEP'/)/&PHIC C*/>I&.E&P*)HE H*"IFH ,EFC&P' *F> CH',) P*IF here because thry impro$e diastoloic %illing o% $entricles by increasing duration o% diastole by reducing heart rate!and also decreasing o(ygen demand! DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD IFB'C)I"' 'F>&C*/>I)I, C*)'H&/E ,OOOOOOO!!!C*2,I)I"' &/H*FI,. F*)I"' H'*/) "*#"' OO!!,!"I/I>*F,(Q;<),'F)'/&C&CC2,(7;<), >*.*H'> H'*/) "*#"'OO ,!"I/I>*F, I!"! >/2H *B2,'/,OOOOO,!*2/'2, P/&,)H')IC "*#"' 'F>&( ithin %irst 7months)O!,!'PI>'/.I>I, P/&,)H')IC "*#"' 'F>&(R7 months)OOO!,!"I/I>*F, DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD */(aortic regurgitation) /1 *,E.P)&.*)IC6&B,'/"*)I&F *F> /'H2#*/ B&##&N2P ,E.P)&.*)IC6*&/)IC "*#"' /'P#*C'.'F) %ollo ing stabili3ing pt %or CCB (digo(in,diuretic and ace inhibitors)! P&,)&P'/*)I"' patient de$eloping sudden drop in BP %ollo ing trying to sit up in blood, ith >I,)'F>'> I2H2#*/ "'IF,,/BBB &F 'LH,B/*>EC*/>I* >iagnosis6.*,,I"' P2#.&F*/E '.B&#I,.!