Multi-infarct dementia, also known as vascular dementia, occurs when blood flow in the small blood vessels supplying the brain is obstructed by blood clots. Each of these clots prevents oxygen from reaching a small part of the brain, and this causes tissue death (infarcts) in the affected parts. Infarcts occur in a number of distinct episodes. People who have multiple small infarcts are at increased risk of a major stroke, which can be life-threatening.

The risk of multi-infarct dementia is increased by atherosclerosis in which fatty deposits build up in the artery walls, causing them to become narrowed and increasing the risk of clots forming. The risk of atherosclerosis is increased if a person has high blood pressure. Lifestyle factors, such as eating a high-far diet and smoking, can also contribute to the development of atherosclerosis. Multi-infarct dementia is more common in men and is more likely to occur in people over the age of 60.

What are the symptoms?

Symptoms of multi-infarct dementia vary from one individual to another because they depend on the part of the brain affected. Unlike other types of dementia, multi-infarct dementia gets incrementally worse following each separate episode. Symptoms are similar to those that occur with other forms of dementia and include:

- Poor memory, particularly when trying to recall recent events.
- Difficulty in making decisions.
- Problems with simple, routine tasks, such as getting dressed.
- Tendency to wander and get lost in familiar surroundings.

It is common for a person with multi-infarct dementia to develop depression and have episodes of agitation. There may be other symptoms, depending on which part of the brain is affected. These may include partial loss of sight and slow, sometimes slurred, speech. Some people begin to walk with very small steps, or develop a weakness or partial paralysis in one leg that can make walking difficult.

What might be done?

Diagnosis of multi-infarct dementia is usually possible from the symptoms, although various tests, such as blood tests, may also be carried out to rule out other types of dementia. The doctor may arrange for CT scanning or MRI of the brain to look for evidence of multiple small infarcts. Although the dementia itself cannot be cured, treatment can help to prevent further infarcts that would make the condition worse. A person with multi-infarct dementia should eat a low-fat diet and take regular exercise. Smokers should stop smoking immediately. Anti-hypertensive drugs, which help to control raised blood pressure, and a daily dose of aspirin, which reduces the risk of blood clots, may be prescribed.

Weakness and loss of movement can be treated with physiotherapy, and speech therapy can help to alleviate speech problems. Antidepressants and counseling maybe used to treat depression.

What is the prognosis?

Many people with multi-infarct dementia find that their symptoms improve for short periods of time but later become worse again. Early recognition of the condition and treatment of risk factors, such as high blood pressure, may prevent further progression of the disorder and increasing disability and reduce the risk of a future, potentially fatal stroke.

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It is normal to become mildly forgetful with increasing age, but severe impairement of short-term memory may be a sign of Alzheimer’s disease. In this disorder, brain cells gradually degenerate and deposits of an abnormal protein build up in the brain. As a result, the brain tissue shrinks, and there is a progressive loss of mental abilities, known as dementia.

Alzheimer’s disease is the most common cause of dementia. In developed countries, the condition affects about 7 in 100 people by the age of 65 and 3 in 100 people by the age of 85. Sometimes, younger people are affected. The underlying cause of the tissue destruction is unknown, although genetic factors may be involved (liên quan). Studies have found that 15 in 100 people with Alzheimer’s disease have a parent affected by the disorder.

What are the symptoms?

The first symptom of Alzheimer’s disease is usually forgetfulness. The normal deterioration of memory that occurs in old age becomes much more severe and begins to affect intellectual ability. Memory loss is eventually accompanied by other symptoms, which may include:

- Poor concentrarion.
- Difficulty in understanding written and spoken language.
- Wandering and getting lost, even in familiar surroundings.

In the early stages of the disease, people are usually aware that they have become more forgerful. This may lead to derpression and anxiety. Over a longer period, the existing symptoms may get worse and additional symptoms may develop. These may include:

- Slow movements and unsteadiness when walking.
- Rapid mood swings from (thay đổi) happiness to tearfulness.
- Personality changes, aggression, and feelings of persecution.

Sometimes people find it difficult to sleep and become restless at night. After several years, most people with the disease cannot look after themselves and need full-time care.

How is it diagnosed?

There is no single test that can be used to diagnose Alzheimer’s disease. The doctor will discuss the symptoms with the affected person and his or her family. Tests may be arranged to exclude other possible causes of dementia. For example, blood tests may be carried out to check for vitamin B deficiencies. CT scanning, PET scanning, or MRI may be carried out to exclude other brain disorders, such as multi-infarct dementia, subdural haemorrhage, or a brain tumour. An assessment of mental ability, which may include memory and writing tests, may be used to determine the severity of the dementia.

What is the treatment?

There is no cure for Alzheimer’s disease, but drugs such as donepezil may slow the loss of mental function in mild to moderate cases. Some of the symptoms that are sometimes associated with Alzheimer’s desease, such as depression and sleeping problems, can be relieved by antidepressant drugs. A person who is agitated may be given a sedative drugs to calm him or her down.

Eventually, full-time care may be necessary, either at home or in a nursing home. Caring for person who has Alzheimer’s disease is often stressful, and cares need practifal and emotional support, especially if the affected person starts to become hostile and aggressive. Support groups can help a person to cope with caring for an elderly relative with the disease. Most people with Alzheimer’s disease survive for up to 10 years from the time of diagnosis.

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Dementia is a combination of memory loss, confusion, and general intellectual decline. The affected person may not realize that there is anything wrong, but his or her condition is usually distressing for close friends and family. Poor memory alone is not a sign of dementia because some memory impairment is a natural part of aging. Dementia is relatively common in elderly people, with about 1 in 10 people in the UK over the age of 65 affected to some degree. Although dementia is usually progressive and cannot be treated, in about 1 in 10 cases the underlying cause is treatable. An elderly person with severe depression may seem to have dementia because the conditions have similar features, such as forgetfulness.

What are the causes?

The underlying abnormality in dementia is a decline in the number of brain cells, resulting in shrinkage of brain cells. Alzheimer’s disease, which occurs mainly in people over 65 and may run in families, is the most common cause of dementia. In multi-infract dementia, blood flow in the small vessels of the brain is blocked by blood clots. Less common causes of dementia include other brain disorders, such as Huntington’s disease. Parkinson’s disease, and Creutzfeldt-Jacob disease.

Dementia may also occur in young people. For example, people with AIDS related dementia. Long-term abusers of alcohol are at risk of dementia because of derect damage to the brain tissue and because their poor diet often leads to vitamin B1 deficiency. Severe vitamin B1 can cause the brain disorder called as WernickeKorsakoff syndrome. In pernicious anaemia, there is a deficiency of vitamin B12 due to impaired absorption in the digestive tract. A severe deficiency can result in dementia. The disorder may also follow a serious head injury. Certain drugs, such as anticovulsant drugs and mood-stabilizing drugs, may cause memory impairment similar to that of dementia.

What are the symptoms?

The symptoms may develop gradually over a few months or years, depending on the cause. They may include:

- Impairment of short-term memory.
- Gradual loss of intellect, affecting reasoning and understanding.
- Difficulty engaging in conversations.
- Reduced vocabulary.
- Emotional outbursts.
- Wandering and restlessness.
- Urinary incontinence.

In the early stages of the disorder, a person is prone to becoming anxious or depressed due to awareness of the memory loss. As the dementia gets worse, the person may become more dependent on others.

What might be done?

The doctor may arrange for the person to have tests to look for the underlying cause and to exclude other disorders. If memory loss is due to a deficiency of one or more of the B vitamins, injections of vitamin supplements may be given. Symptoms that are caused by certain drugs may be relieved by a change of medication. Most other causes of dementia cannot be treated, but drugs may relieve some symptoms. For example, depression may be treated with antidepressants.

A person who has dementia usually needs support at home and may eventually need full-time care in a nursing home. Carers may also need support.

CARING FOR SOMEONE WITH DEMENTIA

If you are taking care of someone with dementia, you need to balance his or her needs with your own. In the early stages, it is important to allow the person to remain as independent and active as possible. As the disorder progresses, there are several measures you can take which help to compensate for the person’s failing memory, loss of judgment, and unpredictable behaviour:

- Put up a bulletin board with a list of things that need to be done during each day.
- If wandering is a problem, persuade the person to wear a badge with your contact details and phone number on it.
- Place notes around the house that help the person to remember to turn off appliances.
- Consider installing bath aids to make washing easier.
- Try to be patient. It is common for people with dementia to have frequent mood changes.
- Give your self a break whenever you can by finding someone who can help for a few hours.
- Join a carers’ support group and investigate day centres and respite care opinions.

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In a subdural haemorrhage, a vein in the subdural space is torn due to a head injury. The subdural space lies between the two outer membranes of the three membranes that surround the brain. Subsequent bleeding into the subdural space causes a blood clot, known as a haematoma, to form. As the blood clot enlarges, it compresses the surrounding brain tissue, causing symptoms such as headache and confusion.

A subdural haemorrhage is a potentially life-threating condition that requires prompt medical treatment. It is the most common cause of death from contact sports such as boxing.

What are the types?

After a head injury, bleeding may occur within minutes (acute subdural haemorrhage) or blood may build up slowly over a period of days or even weeks (chronic subdural haemorrhage).

An acute subdural haemorrhage may follow a severe blow to the head, the type of injury sustained in a road accident or while playing contact sports. Bleeding occurs immediately, and the blood clot enlarges quickly.

A chronic subdural haemorrhage can result from an apparently trivial head injury, especially in the elderly. Bleeding is slow, and it may be several months before the blood clot begins to cause symptoms. Chronic subdurall haemorrhage often affects people who have frequent falls and therefore occurs more commonly in elderly people or in people who drink excessive amounts of alcohol. Disorders or treatments that impair blood clotting, such as treatment with drugs that prevent blood clotting, also increase the risk of chronic subdural haemorrhage.

What are the symptoms?

Symptoms may develop at any time between hours and a few months after the head injury, depending on whether the subdural haemorrhage is acute or chronic. In both types, symptoms are variable and often fluctuate in severity. The symptoms of acute subdural haemorrhage may include:

- Drowsiness.
- Confusion.
- Coma.

The symptoms of a chronic subdural haemorrhage may include:

- Headaches.
- Gradually developing confusion and drowsiness.
- Visual disturbances.

In acute and chronic subdural haemorrhage, the symptoms may also include seizures, vomiting, and progressive muscle weakness or paralysis on one side of the body. If these symptoms develop, seek medical attention immediately.

What might be done?

If your doctor suspects that you have a subdural heamorrhage, he or she will arrange for CT scanning or MRI of your brain to look for a clot. If the condition is confirmed, a surgical procedure in which blood is drained through small holes made in the skull will probably be necessary.

In all cases, the prognosis is determined by the size and location of the clot. Many people recover rapidly, but some residual symptoms, such as weakness, may persist. If the haemorrhage has affected a large area of brain, the condition may be fatal.

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A subarachnoid haemorrhage occur when an artery near the brain ruptures spontaneously and leaks blood into the subarachnoid space, the erea between the middle and innermost of the three membranes that cover the brain. When this happens, the immediate symptom is an intensely painful headache.

Subarachnoid haemorrhage is rare, affecting only about 1 in 10,000 people in the UK each year. When the condition does occur, it is life-threatening and needs emergency medical attention.

What are the causes?

About 7 in 10 subarachnoid haemorrhages are caused by the rupture of a berry aneurysm, an abnormal swelling in an artery often found at a Y-shaped junction in the arteries that supply the brain. Berry aneurysms are thought to be present from birth, and there may be one or several. The aneurysms usually rupture between the ages of 40 and 60.

A further 1 in 10 subarachnoid haemorrhages are the result of a rupture of a knot of arteries and veins on the surface of the brain. The defect, known as an arteriovenous malformation, is present from birth, but haemorrhages do not occur until between the ages of 20 and 40. The cause of 2 in 10 subarachnoid haemorrhages s unknown.

In people who are at risk, subarachnoid haemorrhage may be triggered by intense exertion. The disorder is more common in people who have high blood pressure.

What are the symptoms?

The onset of symptoms is usually sudden and without warning. However, in a minority of cases, a headache comes on gradually a few hours before the haemorrhage occurs. Typical symptoms may include the following:

- Sudden, severe headache.
- Nausea and vomiting.
- Stiff neck.
- Dislike of bright light.
- Irritability.

In a few minutes, these may lead to:

- Confusion and drowsiness.
- Seizures.
- Loss of consciousness.

The body may react to the haemorrhage by constricting the arteries in the brain. As a result, the supply of oxygen to the brain is further reduced, and this may cause a stroke, possibly resulting in muscle weakness or paralysis.

What may be done?

If a subarachnoid haemorrhage is suspected, the affected person should be admitted to hospital immediately. CT scanning is usually carried out to identify the location and extent of bleeding. A lumbar puncture may need to be performed to look for signs of bleeding into the fluid surrounding the brain and spinal cord. MRI or cerebral angiography may also be performed to look at the blood vessels of the brain.

If a subarachnoid haemorrhage is confirmed, drugs called calcium channel blockers are usually given to reduce the risk of a stroke.

If cerebral angiography shows that one or more berry aneurysms are present, surgery will probably be required. During the operation, clips are applied to the affected arteries to prevent them from bleeding again at a later time. If surgery is carried out early, there is a good chance of recovery. Sometimes, knotted or distended vessels are blocked and made safe without the need for surgery by inserting coils or glue during angiography. If damage to the brain has caused persistent symptoms, such as muscle weakness as a result of a stroke, physiotherapy may be arranged.

What is the prognosis?

Nearly half of all people with a subarachnoid haemorrhage die before they reach hospital. Of those people admitted to hospital, about half are treated successfully, but the remainder have another subarachnoid haemorrhage. If there is no further haemorrhage within the next 6 months or if surgery is successful, further bleeding is unlikely.

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If the blood supply to part of the brain is interrupted, the affected region no longer functions normally. This condition is called a stroke, although today it is often described as a “brain attack” to highlight the need for urgent medical attention. A stroke may be due to either a blockage or bleeding from one of the arteries supplying the brain. There is usually little or no warning of a stroke. Immediate admission to hospital for assessment and treatment is essential if there is to be a chance of preventing permanent brain damage. The after effects of a stroke vary depending on the location and extent of the brain tissue affected. They range from mild, temporary symptoms, such as blurred vision, to lifelong disability or death.

If the symptoms disappear within 24 hours, the condition is known as a transient ischaemic attack, which is a warning sign of a possible future stroke.

How common is it?

Each year, about 120,000 people in the UK have a stroke. The condition is more common in men and in older people. A 70 year old living in the UK is about 100 times more likely to have a stroke than a 40 year old. Although the number of deaths from stroke has fallen over the last 50 years, stroke is still the third most common cause of death in the UK after heart attacks and cancer.

What are the causes?

About half of all strokes occur when a blood clot forms in an artery in the brain, a process called cerebral thrombosis. Other major causes are cerebral embolism and cerebral haemorrhage (bleeding). Cerebral embolism occurs when a fragment of a blood clot that has formed in an other part of the body, such as in the heart or the main arteries of the neck, travels in the blood and lodges in an artery supplying the brain. Just under one-third of all strokes are caused by cerebral embolism. Cerebral heamorrhage, which causes about one-fifth of all strokes, occurs when an artery supplying the brain ruptures and blood seeps out into the surrounding tissue. The blood clots that lead to cerebral thrombosis and cerebral embolism are more likely to form in an artery that has been damaged by atherosclerosis, an condition in which fatty deposits build up in artery walls. Factors that increase the risk of atherosclerosis developing are a high-fat diet, smoking, diabetes mellitus, and high levels of lipids in the blood.

Cerebral embolism may be a complication of heart rhythm disorders, heart valve disorders, and recent myocardial infarction, all of which can cause blood clots to form in the heart. The risk of cerebral embolism, thrombosis, or haemorrhage is increased by high blood pressure. Sickle-cell disease, an abnormality of the red cells, also increases the risk of cerebral thrombosis because abnormal blood cells tend to clump together and block blood vessels. Less commonly, thrombosis is caused by narrowing of the arteries supplying the brain due to inflammation. The inflammation may be due to an autoimmune disorder, such as polyarteritis nodosa, in which the immune system attacks the body’s own healthy tissue.

What are the symptoms?

In most people, the symptoms develop rapidly over a matter of seconds or minutes. The exact symptoms depend on the area of the brain affected. The symptoms may include:

- Weakness or inability to move on one side of the body.
- Numbness on one side of the body.
- Clumsiness, or loss of control of fine movements.
- Visual disturbances, such as blurred vision or loss of vision in one eye.
- Slurred speech.
- Difficulty in finding words and understanding what others are saying.
- Vomiting, and difficulty in maintaining balance.

If the stroke is severe, areas of the brain that control breathing and blood pressure may be affected or the person may lapse into coma. In these circumstances, the outcome can be fatal.

How is it diagnosed?

If you suspect that a person has had a stroke, he or she should be taken to hospital immediately so that a cause can be identified and treatment can begin.

Imaging of the brain, such as CT scanning or MRI, may be used to find out whether the stroke was caused by bleeding or a blockage in a vessel. Cerebral angiography or carotid Doppler scanning may be performed to help to identify narrowed areas of arteries that can be corrected by surgery. Further tests may be carried out to look for the source of an embolus. These tests may include echocardiography to assess the heart valves and heart monitoring to check the heart rhythm.

What is the treatment?

The initial treatment following a stroke is close monitoring and nursing care to protect the person’s airways during recovery. If CT scanning reveals a clot in a blood vessel, immediate treatment with thrombolytic drugs to dissolve the dot may be considered. This treatment may improve the outcome, but it is not given routinely because it increases the risk of bleeding within the brain.

Long-term treatment to reduce the risk of further strokes will depend on the cause of the stroke. If the cause was a cerebral embolism, you may be given drugs such as aspirin or warfarin, which act on clotting factors in the blood to reduce the risk of further clots. If a narrowed artery has been identified, it may be widened surgically. After a cerebral haemorrhage, treatment tends to be focused on the underlying cause, although in a few cases, surgery to remove a clot from the brain is carried out first. Long-term treatment may include antihypertensive drugs to lower blood pressure. If the stroke is the result of inflammation of the arteries, corticosteroids may be given.

In all cases of stroke, rehabilitative therapies, such as physiotherapy and speech therapy, provided in hospital or at home, are essential. Lifestyle changes, such as reducing far in your diet and giving up ‘s smoking, can reduce the risk of another stroke.

What is the prognosis?

The outlook after a stroke is often difficult to predict at first and depends to some extent on the cause. Following a stroke, about one-third of people make a full or almost full recovery. Another third have some disability, and some of these may need long-term care in a nursing home. Symptoms that persist for more than 6 months are likely to be permanent. About 1 in 5 people dies within a month of the stroke.

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Brain abscess are collections of pus. They are rare and if left untreated, can be life-threatening. Pus may collect to form a single abscess or may form several abscesses in different parts of the brain. Brain tissue around the abscess or abscesses becomes compressed, and the brain itself may swell, increasing pressure inside the skull.

People with have impaired immunity, including those with HIV infection and those having chemotherapy, are more likely to develop a brain abscess. The risk of a brain abscess is also higher in intravenous drug users than in other people because reused needles may be contaminated with infectious micro-organisms. Men are twice as likely as women to develop a brain abscess.

What are the causes?

Most brain abscess are caused by a bacterial infection that has spread to the brain from an infection in nearby tissues in the skull. For example, the infection may spread from a dental abscess or from an infection in the sinuses. If the skull is penetrated, bacteria may enter the brain and cause infection. Bacterial infection can also be carried in the bloodstream to the brain from an infection in another part of the body, such as the lungs or the heart. In 1 in 10 cases, the source of the infection cannot be found. Occasionally, a brain abscess may be the result of a fungal infection.

What are the symptoms?

The symptoms of a brain abscess may develop in a few days or gradually over a few weeks. They may include:

- Headache.
- Fever.
- Nausea and vomiting.
- Stiff neck.
- Seizures.

Other symptoms, including speech and vision problems or weakness of one or more limbs, may develop depending on which part of the brain is affected. Without treatment, consciousness may be impaired and may lead to coma.

What might be done?

If your doctor suspects a brain abscess, you will be admitted to hospital immediately. The diagnosis can be confirmed by MRI or CT scanning of the head. You may have blood tests to identify the infecting organism and X-ray to look for its source.

Brain abscess caused by bacterial infections are treated with high doses of antibiotics, given intravenously at first and then orally for about 6 weeks. If the abscess is large or causing considerable brain swelling, a small hole may be drilled through the skull under general anaesthesia to allow pus to drain. The pus is then analysed to identify the infecting organism. You may have corticosteroids to control swelling of the brain. Anticonvulsant drugs may be prescribed to reduce the risk of seizures. In severe cases, mechanical ventilation in an intensive care unit may be needed.

What is the prognosis?

Up to 8 in 10 people recover from a brain abscess if treatment is begun early. However, some have persistent problems, such as seizures, slurred speed, or weakness of a limb.

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In a transient ischaemic attack, part of the brain suddenly and briefly, fails to function proberly because it is temporarily deprived of oxygen by blockage of its blood supply. Transient ischaemic attacks can last for anything from a few seconds to 1 hour and have no after-effects. However, if the symptoms persist for longer than 25 hours, the attack is classified as a stroke.

In the UK, about 1 in 2 2,000 people has a transient ischaemic attack, more commonly after the age of 45. attacks are three times more common in men. It is important that a transient ischaemic attack is not ignored because there is a strong possibility that it may be followed by a stroke. Without treatment, about 1 in 3 people who has an attack goes on to have a stroke later on.

What are the causes?

Two conditions can lead to blockage of an artery supplying the brain. A blob clot, called a thrombus, may develop in an artery, or a fragment from a blood clot, called an embolus, may detach itself from elsewhere in the body and travel in the blood to block an artery.

A thrombus usually forms in blood vessels that are affected by atherosclerosis, a condition in which fatty deposits build up in the vessel wall. People at increased risk of atherosclerosis include smokers and those who have a high-fat diet. People who have an inherited tendency towards high levels of fat or people with diabetes mellitus are at risk. High blood pressure increases the risk of atherosclerosis.

The emboli that cause transient ischaemic attacks usually originate in the heart, the aorta (the main artery of the body), or the carotid arteries in the neck. Blood clots are more likely to form in the heart if it has been damaged by a heart attack, if the heartbeat is irregular, of if the heart valves are damaged or have been replaced. Sickle-cell disease can also increase the risk of transient ischaemic attacks because abnormally shaped red blood cells tend to clumps together and block blood vessels.

What are the symptoms?

The symptoms of a transient ischaemic attack usually develop suddenly and are often short-lived, lasting for only a few minutes. Symptoms vary depending on which part of the brain is affected and may include the following:

- Loss of vision in one eye or blurred vision in both.
- Slurred speech.
- Problems understanding what other people are saying.
- Numbness on one side of the body.
- Weakness or paralysis on one of the body, affecting one or both limbs.
- Feeling of unsteadiness and general loss of balance.
- Brief loss of consciousness.

Although the symptoms of transient ischaemic attacks disappear within an hour, attacks tend to recur. People may have a number of attacks in one day or over several days. Sometimes, several years may elapse between attacks.

How are they diagnosed?

Your doctor will carry out a physical examination, which will include checking your blood pressure, heart rhythm, and neurological function. He or she may arrange for CT scanning or MRI of your brain to look for other causes of your symptoms. You might also have ultrasound scanning of the arteries in your neck to look for narrowing. If these arteries are significantly narrowed, further imaging tests will be carried out to assess the severity of the narrowing. For example, you may have cerebral angiography, in which X-rays are taken of the arteries that supply the brain.

Test to look for the source of the blood clots include echocardiography, which is used to look at the structure of your heart and the movement of its valves.

Your heart rate may also be monitored for 24 hours to look for irregularities in your heart rhythm.

Your may have blood tests to look for other factors that increase the risk of having a transient ischaemic attack, such as diabetes mellitus and hyper-lipidaemias. Blood tests may also be used to check for blood disorders that increase the risk of a clot forming.

What is the treatment?

Once a transient ischaemic attack has been diagnosed, the aim treatment is to reduce your risk of having a stroke in the future. You will be advised to reduce the amount of fat in your diet and if you smoke, you should stop. If you have diabetes mellitus, you should make sure your blood glucose levels are well controlled. Your doctor will prescribe appropriate drugs to treat high blood pressure or an irregular heartbeat if you have either of these conditions.

Treatment after a transicent ischaemic attack can be as simple as taking half an aspirin daily to help to prevent blood vessels. Other drugs that help to prevent blood clotting, such as warfarin, may be prescribed if emboli originate from clots that have formed in the heart.

If your doctor finds that the arteries in your neck are severely narrowed, he or she may suggest that you have a surgical procedure called a carotid endarterectomy to clear fatty deposits from the narrowed arteries. Alternatively, you may be referred for a surgical procedure called balloon angioplasty, in which a small balloon is inserted into the affected artery or arteries. Once in place, the balloon is inflated to open up the narrowed section of artery. Both of these procedures increase the diameter of the blood vessel and improve the blood supply to the brain.

What is the prognosis?

Transient ischaemic attacks may occur intermittently over a long period or they may stop spontaneously. Of those people who have a transient ischaemic attack, about 1 in 5 will have a stroke within a year. The more frequently you have transient ischaemic attacks, the higher your risk of having stroke in the future. However, if you take appropriate steps to change aspects of your lifestyle, such as giving up smoking and adopting a low-fat diet, you will reduce the risk of having further transient ischaemic attacks or a stroke.

TEST CAROTID DOPPLER SCANNING

Carotid Doppler scanning uses ultrasound to look at the flow of blood through blood vessels in the neck. The procedure is generally used to investigate disorders such as transient ischaemic attacks or stroke.

Ultrasound waves from a transducer produce a picture of the blood flow, which can reveal narrowing of the carolid blood vessels in the neck. The procedure takes about 20 minutes and is painless and safe.

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Brain tumours may be cancerous or noncancerous. Unlike most tumours in other parts of the body, cancerous and noncancerous brain tumours can be equally serious. The seriousness of a tumour depends on its location, size, and rate of growth. Both types of tumour can compress nearby tissue, causing pressure to build up inside the skull.

Tumours that first develop in brain tissues are called primary tumours. They may arise from support cells in the brain (gliomas) or from meningiomas, cells in the meninges (the membranes covering the brain). Gliomas are often cancerous, but most meningiomas are noncancerous. Primary brain tumours are slightly more common in men and usually develop between the ages of 60 and 70. Some types only affect children.

Secondary brain tumours (metastases) are more common than primary tumours. They are always cancerous, having developed from cells that have been carried in the blood from cancerous tumours in areas such as the breast or the lungs. Several metastases may develop in the brain simultaneously.

What are the symptoms?

Symptoms usually occur when a primary tumour or metastasis compresses part of the brain or raises the pressure inside the skull. They may include:

- Headache that is usually more severe in the morning and is worsened by coughing or bending over.
- Nausea and vomiting.
- Blurred vision.

Other symptoms tend to be related to whichever area of the brain is affected by the tumour and may include:

- Slurred speech.
- Unsteadiness.
- Double vision.
- Difficulty in reading and writing.
- Change of personality.
- Numbness and weakness of the limbs, on one side of the body.

A tumour may also cause seizures. Sometimes, a tumour blocks the flow of the cerebrospinal fluid, which circulates in and around the brain and spinal cord. As a result, the pressure inside the ventricles (the fluid-filled spaces inside the brain) increases and causes further compression of brain tissue. Left untreated, drowsiness can develop, which may eventually progress to a state of coma and death.

How are they diagnosed?

If your doctor suspects a brain tumour, he or she will refer you to for immediate assessment by a neurologist. You will have CT scanning or MRI of the brain to look for a tumour and check its location and size. If these tests suggest that a tumour has spread from a cancer elsewhere in the body, you may need to have other tests, such as chest X-rays or mammography, to check for tumours in the lungs or breasts. Cerebral angiography may be performed to look at blood flow around the tumour. You may also need to have a brain biopsy, in which a sample of the tumour is removed surgically under general anaesthesia. The sample is then examined in a laboratory to find the type of cell from which the tumour has arisen.

What is the treatment?

Treatment for brain tumours depend on whether there is one tumour or several, the precise location of the tumour and the type of cell affected. Primary brain tumours may be treated surgically. The aim of surgery is to remove the entire tumour, or as much of it as possible, with minimal damage to the surrounding brain tissue. Surgery will probably not be an option for tumours located deep within the brain tissue. Radiotherapy may be used in addition to surgical treatment, or as an alternative to it, for both cancerous and noncancerous primary tumours.

A brain metastases are often multiple, surgery is not usually an option. However, in cases where there is a single metastasis, surgical removal may be successful. Multiple tumours are usually treated with radiotherapy or, less commonly, with chemotherapy.

Other treatments may be necessary to treat the effects of brain tumours. For example, the drug dexamethasone may be given to reduce the pressure inside the skull, and anticonvulsant drugs may also be prescribed to prevent or treat seizures. If a tumour blocks the flow of cerebrospinal fluid in the brain and fluid builds up in the ventricles, a small tube may be inserted through the skull to bypass the blockage.

You may also benefit from treatments for the physical effects of the tumour, such as physiotherapy to help with mobility problems or speech therapy for speech problems.

What is the prognosis?

The general outlook for brain tumours depends on their location, size, and rare of growth. The outcome is usually better for a noncancerous tumour that grows slowly, many people with this type are completely cured by surgery.

The outlook for other tumours depends on the type of cell they affect and whether they can be surgically removed. About 1 in 4 people is alive 2 years after diagnosis of a primary cancerous brain tumour, but few people live longer than 5 years. Most people with brain metastases do not live longer than 6 months, although in rare cases, a person with a single metastatic tumour may be curred.

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The uterus is normally inclined up-wards and forwards. In about 1 in 10 women the uterus is titled backwards, lying close to the rectum. This condition is known as a retroverted uterus and is a harmless variation of the normal position. There is often no cause for condition, although if may occur after childbirth or because an ovarian cyst pushes the uterus backwards.

A retroverted uterus usually causes no symptoms and does not affect fertility, pregnancy, or childbirth. However, you may feel pain during sexual intercourse or have low back-ache, especially during menstrual periods.

What might be done?

Your doctor may be able to feel that the uterus is retroverted during a pelvic examination. If an underlying disorder is though to be causing the condition, laparoscopy may be carried out to view the pelvis and abdominal cavity. Mild painkillers may relieve backache, and pain during intercourse may be relieved through trying a different sexual position. If there is an underlying cause, such as a cyst, this may be treated, allowing the uterus to return to its normal position.

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Viral encephalitis is a rare condition in which the brain becomes inflamed as a result of a viral infection. Often, the meninges, the membranes surrounding the brain and spinal cord, are also affected. Viral encephalitis varies in severity. An attack can be so mild that it causes almost no symptoms and is barely noticeable. However, occasionally it is serious and potentially life-threatening.

What are the causes?

Virus herpes

Many different viruses can cause viral encephalitis. Mild cases are sometimes the result of infectious mononucleosis. In addition, viral encephalitis still occurs as a complication of some childhood infections, such as measles and mumps, although routine immunization has made these disorders much less common.

The most common cause of life-threatening viral encephalitis is the herpes simplex virus, particularly in people with HIV infection. In tropical countries, viral encephalitis can be caused by mosquito and tick borne infections, such as yellow fever.

In the past, the disorder was frequently caused by infection with the polio virus. However, this disease is now rare in developed countries as a result of routine immunization.

What are the symptoms?

Mild cases of viral encephalitis usually develop gradually over several days and may cause only a slight fever and mild headache. However, in severe cases, the symptoms usually develop quickly over 24-72 hours and may include:

- High fever.
- Intense headache.
- Nausea and vomiting.
- Problems with speech, such as slurring of words.
- Weakness or paralysis in one or more parts of the body.
- Memory impairment.
- Hearing loss.

In the membranes that surround the brain become inflamed, other symptoms such as stiff neck and intolerance of bright light may develop. The person affected may have seizures. In some cases, there is confusion, which may then progress to drowsiness, a gradual loss of consciousness, and coma.

How is it diagnosed ?

If viral encephalitis is suspected, you will be admitted to hospital. Your doctor may arrange for a blood test to look for signs of viral infection. You may also have CT scanning or MRI to look for areas of brain swelling caused by inflammation and to exclude other possible reasons for the symptoms, such as brain abscess. A sample of the fluid surrounding the brain and spinal cord may be taken to look for evidence of infection. You may have an EEG to look for abnormal electrical activity in the brain, which is frequently a sign of viral encephalitis. Rarely, a brain biopsy is performed, in which a sample of tissue is taken from the brain under general anaesthesia and the examined to confirm the diagnosis.

What is the treatment?

Viral encephalitis that is caused y the herpes simplex virus can be treated with intravenous doses of aciclovir and possibly also with corticosteroids to reduce inflammation of the brain. In severe cases, intravenous aciclovir may be given, even if the cause has not been identified. Anticonvulsant drugs may be prescribed if seizures develop. Severely affected people may need to be treated in an intensive care unit.

What is the diagnosis?

It is often difficult to predict the out-come of viral encephalitis. People who have mild encephalitis usually make a full recovery over several weeks, but occasional headache may occur for a few months. However, in severe cases, the condition may be fatal. Incephalitis caused by the herpes simplex virus often produces long-term effects, such as memory problems or muscle weakness. In children, herpes simplex viral encephalitis may cause learning difficulties. The effects of this type of viral encephalitis can usually be minimized if treatment is begun early.

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In meningitis, the meninges, the membranes that cover the brain and spinal cord, are inflamed. The disease is most often caused by a viral or bacterial infection. The viral form of meningitis is the more common and is usually not as severe as bacterial meningitis. The bacterial form is rarer but can be life-threatening. Although both forms of meningitis can occur at any age, bacterial meningitis occurs predominantly in children, and viral meningitis is most common in young adults. In rare cases, meningitis may be caused by a fungal infection. This type predominates in people with AIDS and in those with other disorders that impair the immune system, such as leukaemia.

What are the causes?

Many different viruses can result in meningitis. Among the most common are enteroviruses, such as the coxsackie virus, which can cause sore throats or diarrhoea, and more rarely, the virus that causes mumps. Viral meningitis tends to occur in small outbreaks, most commonly in summer.

Bacterial meningitis most commonly occurs as a result of infection of the meninges with the bacterium Neisseria meningitidis in an otherwise healthy child or teenager. This bacterium is the cause of meningococcal meningitis and has three main types: A, B and C. Type B is the most common in the UK. Although many people carry Neisseria meningitidis bacteria in the back of their throats, only a fraction develop meningitis. Other bacteria that can cause the disease include Haemophilus influenzae (Hib) and Streptococcus pneumoniae, both of which can also cause infections in the lungs and the throat.

Less often, bacterial meningitis is a complication of an infection that has already developed elsewhere in the body. For example, the bacterium that causes tuberculosis can spread from the lungs to the meninges.

Bacterial meningitis usually occurs as single cases only. However, there may be small outbreaks, especially in institutions such as schools and colleges. This form of meningitis is most common during the winter.

People who have a weakened immune system as a result of an existing illness or a particular treatment, such as people with HIV infection or those having chemotherapy, are at increased risk of all types of meningitis.

What are the symptoms?

Initially, meningitis may produce vague flu-like symptoms, such as mild fever and aches and pains. More pronounced symptoms may then develop. Symptoms are the most severe in bacterial meningitis and develop rapidly, often within a few hours.

The symptoms of viral meningitis may take a few days to develop, while in fungal and tuberculosis meningitis, symptoms develop slowly and may take several weeks to become pronounced.

In adults, the main symptoms of meningitis may include the following:

- Severe headache.
- Fever.
- Stiff neck.
- Dislike of bright light.
- Nausea and vomiting.

In meningococcal meningitis, a rash of flat, reddish-purple lesions, varying in size from pinheads to large patches, that do not fade when pressed.

Unless prompt treatment is given, bacterial meningitis may lead to seizures, drowsiness, and coma. In some cases, pus collects, which results in compression of nearby tissue.

What might be done?

If meningitis is suspected, immediate medical attention and admission to hospital is necessary. Intravenous antibiotics are started immediately. A sample of fluid from around the spinal cord is the taken and tested for evidence of infection. CT scanning or MRI may also be carried out to look for a brain abscess.

If bacterial meningitis is confirmed by the lumbar puncture test, antibiotics are continued for at least a weeks. If meningitis is found to be caused by tuberculosis bacteria, anti-tuberculous drugs will be given. In cases of bacterial meningitis, continuous monitoring in an intensive care unit is often needed. Intravenous fluids, anti-convulsant drugs, and drugs to reduce inflammation in the brain, such as corticosteroids, may be given.

There is no specific treatment for viral meningitis. As long as bacterial meningitis has been excluded by tests, people with viral meningitis are usually allowed to go home if they are well enough. They may be given drugs to relieve symptoms, such as painkillers for headaches. Fungal meningitis is treatment with intravenous antifungal drugs in hospital.

What is the prognosis?

Recovery from viral meningitis is usually complete within 1-2 weeks. It may take weeks or months to make a complete recovery from bacterial meningitis. Occasionally, there may be long-term problems, such as impaired hearing or memory impairment due to damage to a part of the brain. About 1 in 10 people with bacterial meningitis dies despite treatment. Deaths most commonly occur in infants and elderly people.

Can it be prevented?

People in close contact with someone with meningococcal meningitis are usually given antibiotics for 2 days. This treatment kills any meningococcal bacteria that may be present in the back of the throat and prevents their spread to other people. Children are immunized against Haemophilus influenza type B (HiB) and Neisseria meningitis type C. Teenagers are also immunized against Neisseria meningitis type C unless they have been immunized previously. No vaccine is yet available against type B meningoccal meningitis. People traveling to high-risk areas, such as Africa, may be immunized against types A and C.

TEST LUMBAR PUNCTURE

A lumbar puncture is usually performed to look for evidence of meningitis or other nervous system disorders, such as multiple sclerosis. The procedure is carried out under local anaesthesia and takes about 15 minutes. During the procedure, the pressure of the cerebrospinal fluid is checked, and a sample is taken for analysis. You should remain lying down and rest for an hour afterwards to prevent a severe headache.

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People with narcolepsy fall asleep at any time of the day, often when carrying out a monotonous task. Sleep may also occur at inappropriate times, such as while eating. Affected people can be awakened easily but may fall asleep again soon afterwards. Narcolepsy can seriously interfere with daily life.

Some people with narcolepsy have vivid hallucinations just before falling asleep. Others find that they are unable to move while they are falling asleep or waking up (sleep paralysis). About 3 in 4 people with narcolepsy also have cataplexy, in which there is a temporary loss of strength in the limbs that causes the person to fall to the ground. Cataplexy is sometimes triggered by an emotional response, such as fear or laughter.

The cause of narcolepsy is unknown, but it can run in families. It affects about 1 in 1,000 people in the UK, usually developing before the age of 20.

What might be done?

Your doctor will probably diagnose narcolepsy from your symptoms. EEG may also be used to record the electrical activity of your brain. These tests may be carried out while you are asleep in a hospital clinic.

You should take regular, short naps during the day and keep busy while you are awake. Your doctor may prescribe amphetamines, to help you to keep awake. Certain tri-cyclic antidepressant drugs are used to in treating people with cataplexy.

Although narcolepsy is usually a life-long condition, in some cases, there is a spontaneous improvement over time.

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In a person who has epilepsy, recurrent seizures or brief episodes of altered consciousness are caused by abnormal electrical activity in the brain. Epilepsy is a common disorder, affecting about 1 in 130 people in the UK.

The condition usually develops in childhood but may gradually disappear. However, elderly people are also at risk of developing epilepsy because they are more likely to have conditions that can cause it such as stroke.

Many people with epilepsy lead normal lives. However, people who have recurrent seizures may have to limit particular aspects of their lifestyle.

What are the causes?

In 6 out of 10 people with epilepsy, the underlying cause is not clear, although a genetic factor may be involved. In other cases, recurrent seizures may be the result of disease or damage to the brain caused by an infection such as meningitis, a stroke, a brain tumour, or scarring following a severe head injury.

In people with epilepsy, seizures may be triggered by lack of sleep or by missing a meal. Other trigger factors include drinking excessive alcohol and visual effects such as flashing lights and flickering television and computer screens.

A single seizure is not labeled as epilepsy. For example, high fever in a child can result in a single febrile convulsion. People who abuse alcohol over a long period may have a seizure, either while drinking heavily or during withdraw from alcohol. Very low blood glucose levels, which can occur as a result of treatment for diabetes mellitus, can also trigger a seizure.

What are the types?

Epileptic seizures may be generalized or partial, depending on how much of the brain is affected by abnormal electrical activity. During a generalized seizure, all areas of the brain are affected at the same time, whereas during a partial seizure only one part of the brain is affected. Generalized seizures fall into two categories: tonic-clonic seizures and petit mal seizures. There are also two types of partial seizure: simple partial seizures and complex partial seizures. Both simple partial and complex partial seizures can become generalized.

Tonic-clonic seizures: this types of seizure may be preceded by a warning of an attack, known as an aura. This aura lasts for few seconds and gives people an opportunity to sit or lie down before they lose consciousness and fall. Auras may consist of a sensation of fear or unease. During the first 30 seconds of a seizure, the body stiffens and breathing may become irregular or stop briefly. This stage is followed by several minutes of uncontrolled movement of the limbs and trunk. After the seizure, consciousness is regained, breathing returns to normal, and the muscles relax. Relaxation of the muscles in the bladder can cause incontinence. The person may be confused and disoriented for a few hours afterwards and may develop a headache. After a tonic-clonic seizure, the person affected usually has no memory of what has happened.

Status epilepticus is a serious condition in which a person has repeated tonic-clonic seizures without regaining consciousness in between. The condition can be life-threatening, and medical attention should be sought urgently.

Petit mal seizures: these seizures are sometimes known as absence seizures. They start in childhood and may continue into adolescence. Petit mail seizures are rare in adults. During as attack, the child loses touch with his or her surroundings and seems to be daydreaming because his or her eyes remain open and staring. Each attack lasts for between 5 and 30 seconds, and the child is usually unaware afterwards that anything was wrong. Since the seizures are almost never associated with abnormal movements or the child falling down, they may no be noticed. However, frequent attacks can affect schoolwork.

Simple partial seizures: during a simple partial seizure, the affected person remains conscious. The head and the eyes may turn to one side, the hand, arm, and one side of the face may twitch, or the person may feel a tingling sensation in some of these areas. Temporary weakness or paralysis, of one side of the body may follow an attack. The person may also have strange sensations, such as odd smells, sounds, and tastes.

Complex partial seizures: before this type of seizure, an affected person may experience odd taste or smells or have a feeling of having already experienced what is happening. A brief dream-like state follows during which the person may be uncommunicative. During the attack, there may be smacking of the lips, grimacing and fidgeting. Afterwards, the person may not remember what has happened. Sometimes, a generalized seizure occurs as a progression of the complex partial seizure.

How is it diagnosed?

You should consult a doctor if you lose consciousness for an unknown reason or if someone witnesses you having a seizure. If your child has a seizure, you should also seek medical advice immediately. It is helpful if you can obtain full details of your seizure from a witness so that you are able to give the doctor a reliable account of what happened. The doctor may arrange tests to look for an underlying cause of the seizure, such as a brain tumour or an infection such as meningitis. If no cause is found or if you have recurrent seizures, you may have an EEG also helps to diagnose the particular type of epilepsy because some forms produce a distinctive pattern of electrical activity. Your doctor may also arrange for CT scanning or MRI of the brain to look for structural abnormalities that may be causing epilepsy.

How might the doctor treat it?

If only one seizure has occurred, treatment may not be needed. However, an underlying problem, such as poor control of diabetes, may need to be treated. If you have had recurrent seizures, you will probably be treated with anticonvulsant drugs. Usually, the dose of the drugs is gradually increased until the seizures are controlled. Occasionally, a second anticonvulsant is needed.

You will probably have regular blood tests to monitor drug levels. If you have no seizures for 2-3 years, it may possible to reduce the drug treatment or even stop it, depending on a number of factors including the results of the EEG tests and the brain scan. However, any changes in dosage must be carried out under medical supervision. Up to 1 in 2 people who stop taking anticonvulsant drugs have seizures again within 2 years. If drugs do not control the seizures and a small area of brain tissue is found to be their cause, it may be removed surgically.

People with status epilepticus need to be admitted to hospital immediately, where they will be given intravenous drugs to control the seizures.

What can I do?

If you have epilepsy, you should avoid anything that triggers an attack, such as stress or lack of sleep. You should carry identification that will alert others to your condition in case you have a seizure.
If you witness someone having an epileptic seizure, you can help by turning the person onto his or her side and protecting him or her from self-injury. If the seizure lasts for more than 5 minutes, you should call an ambulance.

What is the prognosis?

About 1 in 3 people who have a single seizure will have another one within 2 years. The risk of recurrent seizures is highest in the first few weeks after an attack. However, the outlook for most people with epilepsy is good, and more than 7 in 10 people go into long-term remission within 10 years.

EEG

Electroencephalography (EEG) is used to diagnose conditions, such as epilepsy, that are associated with abnormal electrical activity in the brain. Electrodes are attached to a person’s scalp, and recordings are made of brain activity with the eyes open and closed. A stroke light may be switched on for short periods to see if brain activity changes. The procedure takes approximately 20-30 minutes and is painless.

LIVING WITH EPILEPSY

If you have recently been diagnosed as having epilepsy, the following points may be helpful:

- Avoid anything that has previously triggered or may trigger a seizure, such as flashing lights.
- Learn relaxation exercises to help you cope with stress, which may trigger seizures.
- Eat and sleep at regular times.
- Avoid drinking too much alcohol.
- Check with your doctor before taking medications that may interact with anticonvulsant drugs.
- Make sure that you have someone with you if you are swimming or playing water sports.
- Wear protective headgear when participating in contact sports.
- Before applying for a driving licence, talk to your doctor and contact the Driver and Vehicle Licensing Agency for regulations.
- Consult an adviser before choosing a career because some types of employment may not be suitable.
- Seek advice from your doctor if you plan to become pregnant.

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Injuries to the neck and back are most commonly caused by traffic accidents. The areas most often damaged are the muscles of the back and neck, the bones of the spine (vertebrae) and the ligaments that hold the bones together.

Injuries to the spine may also damage the spinal cord, which lies in a narrow canal in the vertebrae and carries all the major nerve pathways connecting the limbs and trunk to and from the brain. Damage to the spinal cord may cause numbness and weakness in part of the body. If damage is severe, it can result in paralysis, which may be permanent and even life-threatening. Spinal injuries occur more commonly in young men, often as a result of risk-taking behaviour or playing contact sports.

What are the types?

The most common type of spinal injury is whiplash, in which the ligaments and muscles of the neck are damaged. The spinal cord is not usually affected by this type of injury. Whiplash is caused by sudden, extreme bending of the spine when the neck is “whipped” back, usually as the result of a road accident.

A spinal injury may dislocate or fracture one or more of the vertebrae. The vertebrae may be damaged by an impact, such as being hit by a car, or by compression, usually due to a fall from a considerable height. The spinal cord may be damaged by dislocated or broken vertebrae or by a penetrating injury.

What are the symptoms?

Symptoms of a spinal injury depend on the type and severity of the damage and on which part is injured. A whiplash injury may lead to one or more of the following symptoms:

- Headache.
- Neck pain and stiffness.
- Swelling of the affected area.
- Shoulder pain.

Displacement or damage to vertebrae, including compression of a disc, may cause pain and inflammation. If there is damage to the spinal cord, symptoms occur in other parts of the body. These symptoms may include:

- Loss of sensation.
- Weakness.
- Inability to move the affected part.
- Problems with control of the bladder and bowels.

The areas of the body that are affected by symptoms depend on which part of the spinal cord has been damaged. The higher up the spinal cord the damage has occurred, the more parts of the body will be affected. For example, damage to the mid-chest area of the spine may cause weakness and numbness in the legs but will not affect the arms. If the spinal cord is severely damaged in the neck area, there may be total paralysis of all four limbs (quadriplegia), the trunk and muscles that control breathing and death may result.

Anyone who has a suspected neck or spinal injury must not be moved without medical supervision. Emergency first-aid measures should be carried out and medical help sought at one.

How are they diagnosed?

Once the injured person is in hospital, a full neurological assessment will be performed. This will include measuring the person’s responses to different kinds of stimuli, which helps to assess whether the spinal cord has been damaged. If there is damage, CT scanning or MRI may be used to determine its nature and extent. If a fracture of the vertebrae is suspected, X-rays of the spine may be taken.

What is the treatment?

If there is ligament and muscle damage, but the vertebrae are undamaged and unlikely to become displaced, bed rest and regular monitoring will probably be the only treatments that are needed. Nonsteroidal anti-inflammatory drugs may be used to relieve pain and swelling of the tissues, and physiotherapy may be required to strengthen the damaged muscles. If the injury has caused vertebrae to become dislocated or damaged, the affected bones will need to be stabilized. Surgery may be carried out to realign damaged vertebrae and prevent possible damage to the spinal cord. People who have irreversible damage to the spinal cord may be paralysed. Sometimes, early treatment with drugs reduces inflammation and limits the extent of the damage. Long-term physiotherapy is necessary to maintain muscle strength.

What is the prognosis?

Recovery from a spinal injury involving only muscles and ligaments is likely to take 4-6 weeks. Fractures usually heal in 6-8 weeks. If the spine is stable and there is no damage to the spinal cord, the person usually makes a complete recovery. When paralysis occurs, a long period of rehabilitation is needed. If there is no improvement after 6 months, the paralysis is likely to be permanent.

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When a person does not respond to external stimuli because of brain damage, he or she is in a sate of coma. In some cases, damage may affect the whole brain, including the brainstem. This part of the brain controls many of the body’s vital automatic functions, such as heart rate and breathing. If the brainstem is severely damaged, such as after a head injury, these vital functions maybe affected. If this damage is irreversible, the person may certified as brain dead.

A person who is brain dead is unable to respond to any stimuli and cannot breathe independently. Without a life support machine, death occurs within a few minutes and even with life support, death occurs within a few days.

What might be done?

If doctors believe that brain death has occurred, a series of tests is carried out by two experienced medical consultants to confirm the diagnosis. These tests check the person’s response to stimuli and the functions that are controlled by the brainstem. They include testing the ability to breathe independently without a life-support machine.

A diagnosis of brain death is made only if doctors confirm that brain and brainstem functions have been lost, and that the cause has been identified but cannot be reversed, in spite of everything possible having been done.

Someone with brain death will not survive for more than a few days, even with care in an intensive care unit. Full medical support, including mechanical ventilation, will continue while relatives are given counseling. Doctor will discuss the situation fully with the family, and involve family members as much as possible in the decision of when to switch off the life-support machine.

Depending on the age and previous health of the person and the cause of death, relatives may be asked about their wishes regarding organ donation.

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If large areas of both sides of the brain or the brainstem are damaged, coma may result. In persistent vegetative state, the parts of the brain that control higher mental functions, such as thought, are damaged. However, the areas that control vital automatic functions, such as heart rate and breathing, are intact. Although the affected person is physically and mentally unresponsive to noise, light, and other stimuli, he or she can breathe without any assistance. Random movements of the head or limbs may occur.

People in a persistent vegetative state appear to have normal sleep patterns, with their eyes closing and waking. However, they do not appear to feel physical sensation, such a pain, or experience emotional distress. Since areas of the brain that control breathing and other vital functions are intact, a person in a persistent vegetative state can remain a live for months or even years, provided appropriate medical treatment is given.

What might be done?

The diagnosis of persistent vegetative state is made if a person who is unconscious fails to respond to stimulation or to communicate, but vital functions, such as breathing, are maintained. There is no evidence that the mind of the person is functioning consciously.

There is no treatment for persistent vegetative state. However, general supportive measures and nursing care will ensure that affected person is kept as comfortable as possible. A person in a persistent vegetative state can live for several years, but recovery is unlikely.

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Coma is an unconscious state in which a person does not respond to outside stimuli such as sound, light, or touch. There are varying depths of coma. In less severe forms, a person may still respond to certain stimuli, move his or her eyes, cough, and murmur occasionally. A person who is deeply comatose does not make any movements or respond to any form of stimulation.

In the past, being in a state of coma was usually fatal within a short time. Nowadays, recovery is possible because vital functions, such as breathing, can be sustained with life-support machines.

In severe cases of coma, some people lose all automatic functions irreversibly. Other people still retain these basic functions but are otherwise unresponsive. This condition is called a persistent vegetative state.

What are the causes?

A state of coma is caused by damage to the brain. Although such damage is often treatable, very severe damage may be irreversible and is sometimes fatal.

A serious head injury or disorder that prevents blood flow to the brain, such as a stroke or cardiac arrest, may damage enough brain tissue to result in a state of come. Other causes of coma include infections that affect the brain, such as meningitis and viral encephalitis.

Excessively high or low levels of certain substances in the blood may result in a state of coma. For example, a person with diabetes mellitus may become comatose if his or her blood glucose (sugar) level rises or falls excessively. In such circumstances, it is usually possible to reverse the condition with appropriate treatment. A state of coma may also be caused by a drug overdose or by drinking an excessive amount of alcohol or be associated with kidney or liver failure.

How is it diagnosed?

A person who is unconscious on admission to hospital will be examined for evidence of injury and to assess nervous system. Family members and friends will be asked about possible causes. Coma is diagnosed when a person is persistently unconscious, and the depth of coma is assessed by measuring the person’s response to stimuli such as pain. For example, the doctor may rub the sternum (breastbone) or press hard at the base of a nail bed. Blood tests are used to look for an underlying cause, such as a drug overdose, high levels of alcohol, or abnormal levels of glucose. Imaging tests, such as MRI or CT scanning, may be carried out to look for brain damage.

If meningitis is suspected, a lumbar puncture may be performed. In this test, a sample of fluid from around the spinal cord is taken and tested for evidence of infection.

What is the treatment?

A person who is comatose is likely to need care in an intensive care unit, and mechanical ventilation may be necessary if breathing is impaired. If possible, underlying causes are treated immediately. For example, antibiotics are given for an infection. The level of consciousness is assessed at regular intervals. Monitoring the pressure inside the skull may also be necessary because a sate of coma may be associated with raised pressure. If the pressure rises, drugs can be given to reduce it.

What is the prognosis?

If brain damage is minor or reversible, a person may come out of a state of coma and make a full a recovery. However, sometimes it is difficult for doctor to predict the likelihood of a complete recovery. Deep coma caused by severe head trauma often leads to long-term neurological problems. Problems may include muscle weakness or changes in behaviour for which long-term treatments such as physiotherapy or occupational therapy may be needed. If the damage to the brain is severe and irreversible, particularly if the brainstem has been affected, the person is unlikely to recover, and death may be the eventual outcome.

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Many people sustain a head injury at some time in their lives, but most are minor with no long-term consequences. For example, from time to time most children fall over and bump their heads. However, head injuries can be serious and are a major cause of death in young men. About 1 million people in the UK attend hospital each year as a result of a head injury, and more than a quarter require admission. Road accidents are the single largest cause of head injuries, while sports injuries, falls, and assaults, account for most of the remainder.

The severity of a head injury should not be judged simply by appearance because serious brain damage can occur with no sign of damage to the scalp or skull.

What are the types?

Head injuries vary in severity and can damage the scalp, skull, or brain, or a combination of all three. In some head injuries, the eyes may also be damaged.

Scalp injuries alone are usually minor and have no long-term harmful consequences. However, a small cut to the scalp may result in profuse bleeding because many of the blood vessels are close to the skin surface.

As a result, the injury often appears worse than it is.

Fractures of the skull may result from a blow to the head. There may be no bleeding from the scalp, but fractures are sometimes associated with bleeding inside the skull or damage to the brain.

The brain can be damaged directly or indirectly. Direct damage usually occurs in conjunction with a skull fracture or after a penetrating injury, such as a stab wound. Indirect damage tends to occur as a result of a hard blow to the head that does not damage the skull. For example, if the head is struck on one side, the brain can be bruised as it is shaken violently within the skull. The brain may also be damaged by pressure inside the skull caused by a build up of fluid in the brain after an injury. Bleeding between the membranes that cover the brain may also cause dangerous compression of brain tissue.

What are the symptoms?

Initial symptoms often develop soon after a head injury and in minor cases, usually include a mild headache and lump, bruise, or cut on the scalp. However, an injured person may appear well at first, and then symptoms that can be indications of a more serious head injury develop hours or even days later. These symptoms include:

- Blurred or double vision.
- Loss of consciousness.
- Headache accompanied by nausea and vomiting.
- Confusion or drowsiness.
- Slurred speech.
- Vomiting.
- Blood or clear fluid leaking from the nose or ears.

In severe cases, the person may be persistently unconscious. Sometimes, a very serious head injury is immediately fatal.

If you have a severe headache or a cut that requires stitches or if additional symptoms develop, you must go to hospital or get medical help at one. E very young child who is unable to describe his or her symptoms should be watched closely after a head injury. If the child vomits or becomes distressed or drowsy, you should seek medical attention immediately. A head injury that cause loss of consciousness should be assessed in hospital without delay.

Are there complications?

Following a head injury, a few people develop long-term problems that continue for several months or more. These problems include frequent headaches, dizziness, poor concentration, and loss of balance. Persistent ringing in the ears may also develop. People such as boxers who sustain repeated head injuries may eventually develop parkinsonism.

If a head injury results in an open wound, bacteria can enter the skull and cause an infection. Rarely, brain damage affect speech, movement, or mental ability. Some injuries may result in recurrent seizures.

What can I do?

If you have sustained a blow to the head but have not lost consciousness and have only a mild headache, it is safe to take paracetamol to relieve the pain. However, painkillers such as aspirin and other nonsteroidal anti-inflammatory drugs should not be taken because they may make bleeding worse.

If you are with someone who has a head injury, you should carry out relevant first-aid treatment. If the person has lost consciousness, however briefly, or if you are concerned about the severity of the injury, you should seek medical advice immediately.

What might be doctor do?

You doctor will examine you and if necessary, will arrange for you to have tests at a hospital. These may include X-rays to look for a fracture and MRI or XT scanning to look for swelling or bleeding. You may also need to be admitted to hospital overnight for observation.

If you have a minor injury, your doctor may advice you rest at home. However, you must seek medical attention if further symptoms develop. A person with a severe head injury is usually admitted to an intensive care unit, where continuous monitoring can be carried out. If there is swelling of the brain, corticosteroids may be given. Antibiotics are given if there is a risk of infection. Surgery may be needed to relieve pressure on the brain caused by a build up of fluid or from the skull pressing on it. You may also need surgery to remove a blood clot.

If brain damage has affected speech or movement, speech therapy, physiotherapy, and occupational therapy may be required.

What is the prognosis?

Most people with a minor head injury recover completely within a few days. The outcome of a serious head injury is often difficult to predict. About 1 in 2 people survives such an injury, although recovery may take up to 2 years, and some impairment, such as speech problems, may remain. In the most severe cases of head injury, there may be paralysis, coma, persistent loss of consciousness, or death.

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Chronic fatigue syndrome is a complex illness that produces extreme fatigue over a prolonged period. The condition has also been called post viral fatigue syndrome, myalgic encephalomyelitis (ME) or chronic fatigue and immune dysfunction syndrome. The condition can be extremely debilitating and may continue for months or years.

Since the symptoms are so variable, chronic fatigue syndrome is often unrecognized or misdiagnosed. This makes it difficult to estimate the number of people affected, but it is though to be about 150,000 in the UK. The condition is most often seen in women aged between 25 and 45, but it can affect children or adults of any age and people from all ethnic groups.

What are the causes?

The cause of chronic fatigue syndrome is unknown, although it is believed that several different factors are likely to be involved. In some cases, chronic fatigue syndrome develops after recovery from a viral infection or after an emotional trauma, such as bereayement. In other cases, there is no specific preceding illness or life event. Sometimes, chronic fatigue syndrome is associated with depression, although it is unclear whether depression is a result of the condition or cause of it.

What are the symptoms?

Although the number and severity of symptoms may vary, the major symptoms of chronic fatigue syndrome are:

- Extreme tiredness lasting at least 6 months.
- Impairment of short-term memory or concentration.
- Sore throat.
- Tender lymph nodes.
- Muscle and joint pain without swelling or redness.
- Un refreshing sleep.
- Headaches.
- Prolonged muscle fatigue and feeling ill after even mild exertion.

Many people who have chronic fatigue syndrome also develop symptoms of depression, such as loss of interest in their work and leisure activities, or of anxiety. Conditions involving an allergic reaction, such as eczema and asthma, may become worse in people who have chronic fatigue syndrome.

How is it diagnosed?

Your doctor may suspect chronic fatigue syndrome if you have had prolonged fatigue for more than 6 months with no obvious cause and you also have at least four of the other symptoms listed above. However, since persistent tiredness is a symptom of many other disorders, including an under-active thyroid gland or adrenal glands and anaemia, your doctor will try to exclude other causes first.

Your doctor will probably perform a general physical examination, and he or she may ask you questions to find out if you have psychological problems, such as depression. Blood tests may also be arranged. If no underlying cause is identified, a diagnosis of chronic fatigue syndrome will be made if your symptoms meet the criteria. Since there is no specific diagnostic test for chronic fatigue syndrome, confirmation of the disorder can take some time.

What are the treatment?

Although there is no specific treatment for chronic fatigue syndrome, there are a number of self-help measures that may help you to cope with the condition. Your doctor may give you drugs to help you to relieve some of your symptoms. For example, headaches and muscle and joint pain may be relieved by painkillers or nonsteroidal anti-inflammatory drugs. Anti-depressant drugs may produce an improvement in your condition even if you have not developed symptoms of depression. You may find cognitive therapy and behavior therapy beneficial. A course of physiotherapy will help to build up your stamina. Your doctor may suggest counseling to help you to cope with your illness and jointing a support group may also be helpful.

What is the prognosis?

Chronic fatigue syndrome is a long-term disorder, but there may be periods of relief from some symptoms. Many people find symptoms are worst in the first 1-2 years. In more than half of all cases, the condition clears up after several years.

WITH CHRONIC FATIGUE SYNDROME

If you develop chronic fatigue syndrome, you are likely to have fluctuating energy levels. You will need to be flexible and adjust your lifestyle to help you to live with the condition. The following self-help measures may be useful:

- Graded exercise may be useful. Try to set yourself a progressive increase in activity week by week.
- Set realistic goals for yourself.
- Make dietary changes: in particular, reduce your intake of alcohol and cut out drinks containing caffeine.
- Try to reduce stress.
- Joint a support group so that you do not feel isolated.

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