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tients with idiopathic pseudotumor cerebri Their observation that the venous pressure drops immediately upon the reduction in CSF pressure supports the notion that the increased venous pressure is secondary (furthermore, they describe patients with normal venous pressures in the sagittal and transverse sinuses) The unsatisfactory nature of all the currently offered theories of causation of pseudotumor cerebri are reviewed extensively by Walker; but at the moment, our reading of the literature suggests that venous stenosis, from granulations or from some yet unde ned functional change, does account for a large proportion of what had previously been considered to be idiopathic However, this mechanism does not apply in all cases How the venous changes relate to obesity and gender is also unclear Perhaps some individuals have a congenital con guration of the venous sinuses that is exaggerated with obesity of elevated systemic venous pressures Some additional comments about the physiologic changes in CSF ow and pressure in relation to alternative mechanisms of pseudotumor may be informative Using the method of constant infusion manometrics, Mann and coworkers demonstrated an increased resistance to CSF out ow, due in their view to an impaired absorptive function of the arachnoid villi Other authors have attributed intracranial venous hypertension to raised intra-abdominal and cardiac lling pressures, the mechanical result of obesity (Sugerman et al) Others, on inconclusive evidence, have attributed benign intracranial hypertension to an increase in brain volume secondary to an excess of extracellular uid or blood volume within the cranium (Sahs and Joynt, Raichle et al) An interesting related nding has been an elevated level of vasopressin in the CSF but not in the blood (Seckl and Lightman) In the goat, this peptide causes a rise in ICP and a reduction in CSF absorption This raises the possibility that the pseudotumor state is due to an aberration of the transit of water in the cerebrum Finally, Jacobson and colleagues have made the provocative observation that serum vitamin A levels (in the form of retinol) are 50 percent higher than expected, on average, in patients with pseudotumor a difference that is not explained by obesity Because the levels were considerably lower than in cases of hypervitaminosis A with pseudotumor (see below), the meaning of these ndings is uncertain Symptomatic Causes of Pseudotumor Cerebri (Table 30-1) The main considerations in cases of generalized elevation of ICP and papilledema in the absence of an intracerebral mass are covert occlusion of the dural venous sinuses, gliomatosis cerebri, occult arteriovenous malformation, and carcinomatous, infectious, or granulomatous meningitis Although occlusion of the dural venous sinuses and their large draining veins is sometimes equated with pseudotumor, these cases are not, strictly speaking, idiopathic When papilledema occurs in the context of a persistent headache, particularly if the pain is centered near the vertex or medial parietal areas or if there are seizures, venous occlusion is likely Venous sinus thrombosis can be detected in most instances by careful attention to the appearance of the superior sagittal and lateral sinuses on the T1-weighted MRI or on the contrast-enhanced CT scans, as discussed in Chap 34 (page 734) Isolated cortical vein thrombosis on the cerebral convexity does not cause pseudotumor A large cerebral arteriovenous malformation (AVM), by causing an increase both of venous pressure and cerebral blood volume, can also give rise to a pseudotumor syndrome In a few of our cases, these changes in the physiology of the cerebral circulation were made evident by the appearance of early venous ow on the angiogram or by thrombosis of the superior sagittal sinus.

The index and the partition can be partitioned on the same partition key This relationship, known as equipartitioning or a local index, means a separate portion of the index for each partition in the database If most of the queries running against your partitioned table will result in partition pruning, equipartitioning amplifies the benefits of this approach An index could be global and partitioned on a different partition key than the associated table This scheme will deliver benefits for some queries where the index partition key can be used for partition pruning, and other benefits for queries where the table partition key can be used An index can also be global and unpartitioned, and the table is partitioned Although this relationship may not produce as large a benefit as equipartitioning, some types of random access will work better this way, as a global index can be accessed with a single read rather than having to probe each index partition

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An acute or subacute symmetrical polyneuropathy is a frequent development in critically ill and septic patients, particularly in those with failure of multiple organs (Zochodne et al) This type of neuropathy causes dif culty in weaning a patient from the ventilator, even as the underlying critical illness comes under control The neuropathic process, predominantly of motor type, varies in severity from an electrophysiologic abnormality without obvious clinical signs to a pronounced quadriparesis with respiratory failure Sensory symptoms and signs are variable but tend to be mild Usually the cranial nerves are spared and there are no overt dysautonomic manifestations In general, the disease appears after several days or more of profound sepsis (now called systemic in ammatory response syndrome SIRS) and multiple organ failure and is preceded in most instances by a confusional state or a depressed state of consciousness ( septic encephalopathy ) The EMG ndings of a primary axonal process with early denervation and a normal CSF distinguish this entity from the typical demyelinative form of GBS Autopsy material has usually disclosed no in ammatory changes in the peripheral nerves As mentioned, differentiating critical illness polyneuropathy from the axonal form of GBS is dif cult and depends on the context in which the illness occurs The toxic effects of drugs and antibiotics and nutritional de ciency must be considered in causation, but rarely can they be established Perhaps some of the many systemic mediators of sepsis are toxic to the peripheral nervous system; tumor necrosis factor has been proposed as one such endogeneous toxin This form of polyneuropathy must also be distinguished from a poorly understood acute quadriplegic myopathy that sometimes complicates critical illness (page 1237) High doses of corticosteroids, particularly in combination with neuromuscular blocking agents, have been implicated The acute myopathy, which affects both distal and proximal muscles, is usually heralded by an elevation in the serum creatine kinase (CK) concentration (at times up to several thousand units) and myopathic potentials in the EMG, and there is a unique degeneration of myo laments in all the muscles This illness is described in more detail in Chap 51.

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Acute Sensory Neuronopathy (Sensory Ganglionopathy)

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