Army Regulation AR 380-5 Security: Army Information Security Program October 2019

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The first step is the hemodynamic stabilization of the patient. The amount of fluid is calculated on an individual basis. [1] It should be noted that although hemodynamic stabilization is necessary, volume overloading should be avoided at all costs and treated with diuresis or renal replacement therapy if indicated. [12]Starch products can lead to tubular damage and hence should be avoided. For a large volume replacement, balanced crystalloids are recommended. The target for hemodynamic stabilization is achieving the mean arterial pressure (MAP) of 65-70 mmHg in non-hypertensive patients. In addition to all the therapeutic modalities, close hourly monitoring of urine output is extremely important to gauge treatment accordingly. [3] Ahmed R, Wilkinson M, Parker G et al. Transverse Sinus Stenting for Idiopathic Intracranial Hypertension: A Review of 52 Patients and of Model Predictions. AJNR Am J Neuroradiol. 2011;32(8):1408-14. doi:10.3174/ajnr.A2575 - Pubmed These otoliths move due to gravity as the head is turning and cause inappropriate signaling that the head is moving when, in reality, it is not. When the vestibular apparatus, semicircular canals, and visual system are in disequilibrium, it elicits the sensation of dizziness. The classic symptoms of BPPV often involve brief episodes of rotational vertigo that are reproducible. [6] Oral non-steroidal anti-inflammatory drugs (NSAIDs). Anti-inflammatory medications, such as aspirin, ibuprofen, naproxen, or cox-2 inhibitors (Celebrex), may reduce pain, swelling, and inflammation caused by AC joint osteoarthritis. Aberrant arachnoid granulations, also referred to as meningoceles, can result in secondary CSF leaks that can present as rhinorrhea, otorrhea, intracranial hypotension, and recurrent bacterial meningitis 7,9. In such patients it is often only after dural repair that intracranial hypertension becomes evident; presumably, the CSF leak from the meningocele normalized pressure 9. Pathology

prominent arachnoid pits/ aberrant arachnoid granulations/small meningoceles typically within the temporal bone and sphenoid wing 9 Bialer O, Rueda M, Bruce B, Newman N, Biousse V, Saindane A. Meningoceles in Idiopathic Intracranial Hypertension. AJR Am J Roentgenol. 2014;202(3):608-13. doi:10.2214/AJR.13.10874 - Pubmed However, depending on the patient, co-existing conditions, and the specific physical therapy program, exercises that focus on stretching and strengthening muscles and maintaining the shoulder’s range of motion may be helpful. The differential diagnosis for dizziness encompasses numerous body systems, such as neurological, cardiovascular, or hematologic. Some studies have shown up to 15% of cases of dizziness in the emergency department are life-threatening. [1]Therefore, it is important to perform a thorough history, and physical exam as the ultimate diagnosis can be benign or life-threatening.Alnemari A, Mansour T, Gregory S, Miller W, Buehler M, Gaudin D. Chiari I Malformation with Underlying Pseudotumor Cerebri: Poor Symptom Relief Following Posterior Decompression Surgery. Int J Surg Case Rep. 2017;38:136-41. doi:10.1016/j.ijscr.2017.07.039 - Pubmed The ligaments surrounding the AC joint are maintained during this procedure to prevent postoperative instability at the joint. In oliguric patients, secondary to renal etiology treatment is mainly focused on supportive care and potential renal replacement therapy to manage the fluid and electrolyte balance to avoid the development of complications. [1] Nicholson P, Brinjikji W, Radovanovic I et al. Venous Sinus Stenting for Idiopathic Intracranial Hypertension: A Systematic Review and Meta-Analysis. J Neurointerv Surg. 2019;11(4):380-5. doi:10.1136/neurintsurg-2018-014172 - Pubmed Wall M, Kupersmith M, Kieburtz K et al. The Idiopathic Intracranial Hypertension Treatment Trial: Clinical Profile at Baseline. JAMA Neurol. 2014;71(6):693-701. doi:10.1001/jamaneurol.2014.133 - Pubmed

Bejjani G. Association of the Adult Chiari Malformation and Idiopathic Intracranial Hypertension: More Than a Coincidence. Med Hypotheses. 2003;60(6):859-63. doi:10.1016/s0306-9877(03)00064-1 - Pubmed Lumbar puncture is central to diagnosis. The CSF composition is normal but the opening pressure is elevated (with 20-25 cm H 2O considered equivocal and >25 cm H 2O considered definitely abnormal). It is controversial whether positioning during lumbar puncture is clinically important, with some insisting that lateral decubitus is the most accurate but others believing the default position for fluoroscopy-guided lumbar puncture, prone, is close enough 25. It should also be noted that opening pressure can vary during the day. One study continuously measuring CSF pressures demonstrated many patients had intermittent pressure waves with amplitudes of 50–80 mmHg (68–109 cm H 2O) that lasted 5 to 20 minutes 26. Doctor and patient should discuss medication in the context of the patient’s lifestyle, severity of pain and medical history. Potential side effects and interaction with other drugs and vitamins/supplements should always be considered. The patient should be educated about the importance of maintaining adequate hydration and instructed to avoid the use of any medication without consulting the physician, especially NSAIDs, which are one of the commonly used medications available over the counter for pain relief. The patient should be recommended to follow the provider’s advice and get regularly followed up by their physician as well as a nephrologist if the physician suggests. Jones O, Cutsforth-Gregory J, Chen J, Bhatti M, Huston J, Brinjikji W. Idiopathic Intracranial Hypertension is Associated with a Higher Burden of Visible Cerebral Perivascular Spaces: The Glymphatic Connection. AJNR Am J Neuroradiol. 2021;42(12):2160-4. doi:10.3174/ajnr.A7326 - PubmedRohr A, Dörner L, Stingele R, Buhl R, Alfke K, Jansen O. Reversibility of Venous Sinus Obstruction in Idiopathic Intracranial Hypertension. AJNR Am J Neuroradiol. 2007;28(4):656-9. PMC7977370 - Pubmed