Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (75 page)

   Adjunctive risk assessment tools such as C-reactive protein, other circulating inflammatory biomarkers, and subclinical atherosclerosis imaging (CT, carotid intimal thickness or CIMT) have emerged within the past decade and have been cautiously included in recommendations for risk assessment in asymptomatic adults (level of evidence B: no randomized trials based on management).

   CRP (along with CT scanning and CIMT) is currently recommended (Class IIa) for asymptomatic moderate-risk individuals in whom lipid lowering therapy is considered based on atherosclerotic risk alone (i.e., LDL-C < 130 mg/dL not on medication).

   Individuals with evidence of peripheral arterial disease, symptomatic carotid disease, asymptomatic carotid disease >50%, diabetes mellitus, and/or abdominal aortic aneurysm are considered to have a coronary heart disease risk equivalent and warrant aggressive preventive therapy akin to established coronary atherosclerosis. In these patients, subsequent lipid assessment is required for titration of therapy. Adjunctive testing for the diagnosis of coronary atherosclerosis (CRP/imaging) is not justified.

   Laboratory Findings

   Core laboratory: Lp(a) and homocysteine are increased.

   Elevated CRP (if first result is >3.0 mg/L, repeating the test at least 2 weeks later when patient is in metabolically stable state free of infection or acute illness is recommended). Persistent values >3.0 mg/L define a high-risk category. The Reynolds Risk Score incorporates CRP into initial risk assessment (
http://www.reynoldsriskscore.org
). Overall the modest strength of CRP inclusion into risk assessment points argues against a causative role in atherosclerosis.

   Coronary artery calcium scores exceeding 100 AU (Agatston units) or 75th percentile are considered high risk for coronary events, as are any carotid plaque or IMT exceeding 75th percentile.

Suggested Readings

Faxon DP, Fuster V, Libby P, et al. Atherosclerotic vascular disease conference: writing group III: pathophysiology.
Circulation.
2004;109:2617–2625.

Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guidelines for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol.
2010;56:e50–e103.

Lloyd-Jones DM. Cardiovascular risk prediction: basic concepts, current status, and future directions.
Circulation.
2010;121:1768–1777.

Chapter 4

Central Nervous System Disorders

Juliana G. Szakacs

Disorders of Cognition and Dementia

Intellectual Disability

Dementia

Alzheimer Disease

Vascular Dementia

Frontotemporal Dementia

Dementia with Lewy Bodies

Parkinson Disease Dementia

Huntington Disease

Disorders of Altered Mental State

Coma and Stupor

Reye Syndrome (Acute Toxic– Metabolic Encephalopathy)

Seizures

Delirium

Disorders with Focal Neurologic Deficits (Neuropathies)

Polyneuropathy (Neuritis/ Neuropathy, Multiple)

Diabetic Polyneuropathy

Cranial Nerve Neuropathy, Multiple

Mononeuropathy

Facial Palsy (Bell Palsy)

Hemianopsia, Bitemporal

Ophthalmoplegia

Oculomotor Nerve Palsy

Trigeminal Neuralgia (TIC Douloureux)

Retrobulbar Neuropathy (Optic Neuritis)

Autonomic Neuropathy

Pseudotumor Cerebri

Disorders of Movement

Parkinson Disease

Progressive Supranuclear Palsy

Huntington Disease

Dystonia

Tourette Syndrome

Cerebral Palsy

Sydenham Chorea

Lesch-Nyhan Syndrome

Essential Tremor

Restless Leg Syndrome

Amyotrophic Lateral Sclerosis (ALS)

Autoimmune Disorders of the CNS

Primary Autoimmune Autonomic Failure

Guillain-Barré Syndrome

Multiple Sclerosis

Neoplastic Disorders of the CNS

Brain Tumor

Glomus Jugulare Tumor (Jugulotympanic Paraganglioma)

Leukemic Involvement of the Central Nervous System

Lymphomatous Involvement of the Central Nervous System

Spinal Cord Tumor

Congenital Disorders of the CNS

Neural Tube Defects

Trauma and Vascular Disorders of the CNS

Central Nervous System Trauma

Acute Epidural Hemorrhage

Subdural Hematoma

Stroke

Cerebral Embolism

Intracerebral Hemorrhage

Berry Aneurysm (Saccular Aneurysm)

Cerebral Vein or Sinus Thrombosis

Hypertensive Encephalopathy