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Kim SH, Kim JS, Kim HY, Lee SI. Transsylvian-Transinsular Approach for Deep-Seated Basal Ganglia Hemorrhage: An Experience at a Single Institution. J Cerebrovasc Endovasc Neurosurg 2015; 17:85-92. [PMID: 26157687 PMCID: PMC4495086 DOI: 10.7461/jcen.2015.17.2.85] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 08/26/2014] [Accepted: 03/31/2015] [Indexed: 12/05/2022] Open
Abstract
Objective Treatment of spontaneous intracerebral hemorrhage (ICH) remains controversial. However, an extensive hemorrhage with a poor mental status is suitable for surgical evacuation. Our experience with the transsylvian-transinsular (TS-TI) microsurgical approach for deep-seated basal ganglia (BG) ICH was investigated. Material and Methods A retrospective review was conducted on 86 patients with BG ICH who underwent an operation at the Department of Neurosurgery of our Hospital from September 2011 to October 2014. Thirteen patients underwent craniotomy and the TS-TI microsurgical approach for hematoma evacuation. Twenty-seven patients underwent conventional craniotomy with the trans-cortical transtemporal (TC-TT) approach, and 46 patients underwent a burrhole operation and hematoma drainage using a frameless stereotaxic device (ST). Results The average age distribution was similar. The preoperative Glasgow coma scale (GCS) was similar for the TC-TT and TS-TI groups. The pre-operative hematoma levels were higher in the TC-TT (109.4 ± 48.6 mL) and TS-TI (96.0 ± 39.0 mL) groups than in the ST group (46.5 ± 23.5 mL). The hematoma removal rate was 77% in the TC-TT group, 88% in the TS-TI group, and 34% in the ST group. The mean maintenance period of a hematoma catheter was 3.6 days in the ST group. The clinical outcome showed correlation with the preoperative neurological symptoms. Conclusion The TS-TI group was superior to the TC-TT group for evacuation of an intracerebral hematoma.
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Affiliation(s)
- Seung Hwan Kim
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jung Soo Kim
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hae Yu Kim
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sun-Il Lee
- Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Mojumder DK, Patel S, Nugent K, Detoledo J, Kim J, Dar N, Wilms H. Pupil to limbus ratio: Introducing a simple objective measure using two-box method for measuring early anisocoria and progress of pupillary change in the ICU. J Neurosci Rural Pract 2015; 6:208-15. [PMID: 25883482 PMCID: PMC4387813 DOI: 10.4103/0976-3147.153229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Measurement of static pupillary size in the ICU is of importance in cases of acutely expanding intracranial mass lesions. The inaccuracies with subjective assessment of pupillary size by medical personnel preclude its use in emergent neurological situations. Objective: To determine if the ratio of pupil to limbus diameter (PLD ratio) measured by a two-box method is a reliable measure of pupil size for detecting early anisocoria and measuring pupillary changes. Materials and Methods: The PLD ratio was defined as the ratio of the pupillary diameter measured at a para-horizontal axial plane with the limbus diameter measured at the same or parallel axial plane. A two-box method was used to estimate the diameters of imaged pupils. Eyes were imaged using an iPhone 4S cellphone camera. Background illumination was measured and kept constant. The pupils of a 78-year-old woman, who presented with a large intra-axial parenchymal hemorrhage, were imaged. The patient had left pupillary miosis in dark but not in bright light. After presenting this case along with the images of the pupillary examination, a group of 21 medical staff were asked several questions on the pupillary examination. Reliability of PLD ratio were assessed via standard error of mean (S.E.M) of PLD ratios for 3 different subjects each imaged under constant illumination and fixation but from different angles to the optical axis. Results: Analysis of questionnaire data together with PLD ratios revealed that ~ 14% and 10% of participants could estimate the pupillary size in darkness and bright light respectively but none were simultaneously accurate indicating that subjective assessment of pupillary size was unreliable. The approach towards a systematic pupillary examination was inconsistent among the participants. The PLD ratio was found to be a reliable measure of pupillary size with standard error of mean below 0.1 mm for the three subjects tested. Conclusion: Static pupillary sizes can be objectively and consistently evaluated using PLD ratios using a two-box method. PLD ratios are resistant, within limits, to changes in imaging angle or choice of para-horizontal axes for measurement.
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Affiliation(s)
- Deb Kumar Mojumder
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Saumil Patel
- Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA
| | - Kenneth Nugent
- Department of Internal Medicine, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - John Detoledo
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Jongyeol Kim
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Nabeel Dar
- Department of Radiology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Henrik Wilms
- Department of Neurology, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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Han SH, Lee HK, Moon JG, Kim CH, Cho TG. Rapid spontaneous reduction of a huge intracerebral hematoma. J Cerebrovasc Endovasc Neurosurg 2012; 14:104-7. [PMID: 23210037 PMCID: PMC3471261 DOI: 10.7461/jcen.2012.14.2.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 04/13/2012] [Accepted: 05/14/2012] [Indexed: 11/23/2022] Open
Abstract
Rapid reduction of a large acute subdural hematoma has been frequently reported. In my knowledge, however, it was rarely reported that rapid spontaneous reduction occurred in large volume of spontaneous intracerebral hematoma (sICH). We describe a patient with a rapid spontaneous decrease in the volume of a large hematoma. A 73-year-old man presented semi-comatose mentality. Initial brain computed tomography (CT) revealed the huge sICH. An emergency operation was planned, but was not performed due to the refusal of patient's family. Therefore, we decided to treat with conservative therapy. However, follow-up brain CT 16 hours after initial scan showed a remarkable reduction of previous sICH. The mechanism involving the spontaneous rapid decrease of the hematoma is presumed to occur through redistribution in brain atrophy, compression effect from the increased intracranial pressure and dilution through a wash out by the cerebrospinal fluid.
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Affiliation(s)
- Sung Hoon Han
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, College of Medicine, Hallym University, Seoul, Korea
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Ohwaki K, Yano E, Nagashima H, Hirata M, Nakagomi T, Tamura A. Blood pressure management in acute intracerebral haemorrhage: low blood pressure and early neurological deterioration. Br J Neurosurg 2011; 24:410-4. [PMID: 20632876 DOI: 10.3109/02688691003746282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECT Lowering the blood pressure (BP) of patients with intracerebral haemorrhage (ICH) can prevent haematoma enlargement but may also promote secondary infarction in areas adjacent to the haematoma, which can lead to neurological deterioration. Little is known about the effects of low BP on early neurological deterioration (END). We conducted a retrospective study to determine whether low BP after admission was associated with END in patients with acute ICH. METHODS We investigated 100 consecutive patients diagnosed with spontaneous ICH. We obtained data on minimum systolic blood pressure (SBP) in the 24 h after admission and related factors and assessed END in this time window. RESULTS END occurred in 38 patients. The frequencies of END by minimum SBP quartile were 52% ( <or= 100 mmHg), 29% (100-120 mmHg), 14% (120-130 mmHg), and 48% ( > 130 mmHg). A logistic regression model for predicting END was developed using SBP at admission, Glasgow Coma Scale at admission, haematoma volume, minimum SBP, and squared minimum SBP. A U-shaped relationship between minimum SBP and END (p = 0.02) was observed, with the lowest risk for END at a minimum SBP of 123 mmHg. The curve was nearly flat for a minimum SBP of 115-130 mmHg, indicating that the risk of END is relatively low across this range of minimum SBPs. CONCLUSIONS Our findings suggest that a minimum SBP of approximately 120-125 mmHg after admission is associated with a beneficial impact on a reduced risk of END.
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Affiliation(s)
- Kazuhiro Ohwaki
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan.
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Park SY, Kong MH, Kim JH, Kang DS, Song KY, Huh SK. Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage. J Korean Neurosurg Soc 2010; 48:399-405. [PMID: 21286475 DOI: 10.3340/jkns.2010.48.5.399] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 06/29/2010] [Accepted: 11/26/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH. METHODS During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups. RESULTS Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma. CONCLUSION Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.
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Affiliation(s)
- Soo Yong Park
- Department of Neurosurgery, Seoul Medical Center, Seoul, Korea
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Martí-Fàbregas J, Martínez-Ramírez S, Martínez-Corral M, Díaz-Manera J, Querol L, Suárez-Calvet M, De Juan M, Santaló M, Marín R, Martí-Vilalta JL. Blood pressure is not associated with haematoma enlargement in acute intracerebral haemorrhage. Eur J Neurol 2008; 15:1085-90. [DOI: 10.1111/j.1468-1331.2008.02254.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
OBJECTIVE Early neurologic deterioration has been studied in patients with intracerebral hemorrhage during hospitalization, but rates and factors associated with prehospital neurologic deterioration (PND) are unknown. We sought to determine the prevalence of PND among patients with intracerebral hemorrhage during Emergency Medical Services transportation to the hospital. DESIGN Historical cohort study. SETTINGS U.S. acute care hospital from 2000 to 2004. PATIENTS Hospitalized patients with a diagnosis of spontaneous intracerebral hemorrhage were identified by codes of the International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). METHODS The initial Glasgow Coma Scale score ascertained at the scene by the Emergency Medical Services was compared with the subsequent evaluation in the emergency department to identify neurologic deterioration (defined as a decrease in Glasgow Coma Scale of > or = 2 points). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 98 patients with acute intracerebral hemorrhage, 22 patients (22%) showed PND during Emergency Medical Services transport, with a mean decrease in the Glasgow Coma Scale score during transport of 6 points. The patients who demonstrated neurologic deterioration tended to have higher diastolic blood pressure at the scene (p = .045), greater rates of intraventricular extension (p < .0001), and radiologic signs of herniation (p < .0001) on initial computed tomographic scan. There was a statistically significant decrease in diastolic blood pressure between the evaluations of the Emergency Medical Services and the emergency department among both patients with and without PND. CONCLUSIONS PND occurs in nearly one fifth of patients with intracerebral hemorrhage. Higher diastolic blood pressure at the scene, intraventricular extension, and radiologically evident herniation seem to be associated with PND. Prospective studies are needed to evaluate the efficacy of Emergency Medical Services interventions to reduce this early clinical deterioration.
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The effect of blood pressure on hematoma and perihematomal area in acute intracerebral hemorrhage. Neurosurg Clin N Am 2006; 17 Suppl 1:11-24. [DOI: 10.1016/s1042-3680(06)80004-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Maruishi M, Shima T, Okada Y, Nishida M, Yamane K. Involvement of fluctuating high blood pressure in the enlargement of spontaneous intracerebral hematoma. Neurol Med Chir (Tokyo) 2001; 41:300-4; discussion 304-5. [PMID: 11458742 DOI: 10.2176/nmc.41.300] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The correlations between changes in blood pressure after admission and hematoma expansion were investigated in 118 patients with spontaneous intracerebral hematoma admitted within 24 hours of onset who underwent serial computed tomography. Multiple logistic regression was performed to assess correlations between hematoma enlargement and clinical characteristics on admission. Hematoma enlargement was predominantly correlated with time of onset (p = 0.01567), and not well correlated with blood pressure at admission (p = 0.07908). Serial changes in blood pressure were investigated in 57 patients admitted within 6 hours of ictus whose blood pressures were monitored every hour from admission. Wilcoxon signed-rank analysis was used to determine the relationships between hematoma enlargement and blood pressure. Patients with hematoma enlargement was significantly correlated with increased blood pressure (p = 0.0004). Increases in blood pressure after admission may be a factor in hematoma enlargement.
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Affiliation(s)
- M Maruishi
- Department of Neurosurgery, Inokuchi Hospital, Higashihiroshima, Hiroshima, Japan
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Murai Y, Takagi R, Ikeda Y, Yamamoto Y, Teramoto A. Three-dimensional computerized tomography angiography in patients with hyperacute intracerebral hemorrhage. J Neurosurg 1999; 91:424-31. [PMID: 10470817 DOI: 10.3171/jns.1999.91.3.0424] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors confirm the usefulness of extravasation detected on three-dimensional computerized tomography (3D-CT) angiography in the diagnosis of continued hemorrhage and establishment of its cause in patients with acute intracerebral hemorrhage (ICH). METHODS Thirty-one patients with acute ICH in whom noncontrast and 3D-CT angiography had been performed within 12 hours of the onset of hemorrhage and in whom conventional cerebral angiographic studies were obtained during the chronic stage were prospectively studied. Noncontrast CT scanning was repeated within 24 hours of the onset of ICH to evaluate hematoma enlargement. Findings indicating extravasation on 3D-CT angiography, including any abnormal area of high density on helical CT scanning, were observed in five patients; three of these demonstrated hematoma enlargement on follow-up CT studies. Thus, specificity was 60% (three correct predictions among five positives) and sensitivity was 100% (19 correct predictions among 19 negatives). Evidence of extravasation on 3D-CT angiography indicates that there is persistent hemorrhage and correlates with enlargement of the hematoma. Regarding the cause of hemorrhage, five cerebral aneurysms were visualized in four patients, and two diagnoses of moyamoya disease and one of unilateral moyamoya phenomenon were made with the aid of 3D-CT angiography. Emergency surgery was performed without conventional angiography in one patient who had an aneurysm, and it was clipped successfully. CONCLUSIONS Overall, 3D-CT angiography was found to be valuable in the diagnosis of the cause of hemorrhage and in the detection of persistent hemorrhage in patients with acute ICH.
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Affiliation(s)
- Y Murai
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
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Flemming KD, Wijdicks EF, St Louis EK, Li H. Predicting deterioration in patients with lobar haemorrhages. J Neurol Neurosurg Psychiatry 1999; 66:600-5. [PMID: 10209170 PMCID: PMC1736365 DOI: 10.1136/jnnp.66.5.600] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To study the clinical course and determine predictors of deterioration in patients with lobar haemorrhages). METHODS A comprehensive review of 61 consecutive patients with lobar haemorrhages was performed. Neurological deterioration was defined as (1) decrease in Glasgow coma sum score by 2 points, (2) new neurological deficit, or (3) clinical signs of brain herniation. A univariate logistic regression was performed and expressed in odds ratios. RESULTS Sixteen of 61 (26%) patients with lobar haemorrhages deteriorated after admission. In a univariate analysis, only a Glasgow coma score <14 predicted deterioration (75% of deteriorators v 24% who did not deteriorate; p<0.0001). Initial CT characteristics predictive of deterioration included haemorrhage volume >60 ml (63% v 16%, p< 0.0001), shift of the septum pellucidum (75% v 36%, p<0.01), effacement of the contralateral ambient cistern (33% v 0%, p<0.0001), and widening of the contralateral temporal horn (50% v 0%, p<0.0001). Patients presenting and deteriorating within 12 hours of ictus declined due to enlargement of the haemorrhage. Those who deteriorated more than 12 hours after initial neurological symptoms, showed increased mass effect secondary to oedema. CONCLUSION-Patients with lobar haemorrhages presenting immediately after ictus are at risk for deterioration from enlargement of the haemorrhage and predictors of deterioration may be absent. Patients with large volume lobar haemorrhages presenting to the emergency department with decreased level of consciousness and shift on CT are at risk for further deterioration from worsening oedema. These patients require close observation and early aggressive management may be warranted.
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Affiliation(s)
- K D Flemming
- Department of Neurology, Neurological and Neurosurgical Intensive Care Unit, Saint Mary's Hospital, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
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Murai Y, Ikeda Y, Teramoto A, Tsuji Y. Magnetic resonance imaging-documented extravasation as an indicator of acute hypertensive intracerebral hemorrhage. J Neurosurg 1998; 88:650-5. [PMID: 9525710 DOI: 10.3171/jns.1998.88.4.0650] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT The aim of this study was to determine the usefulness of magnetic resonance (MR) imaging-documented extravasation as an indicator of continued hemorrhage in patients with acute hypertensive intracerebral hemorrhage (ICH). METHODS The authors studied 108 patients with acute hyperintensive ICH. Imaging modalities included noncontrast-enhanced computerized tomography (CT) scanning, gadolinium-enhanced MR imaging, and conventional cerebral angiography obtained within 6 hours after the onset of hemorrhage. A repeated CT scan was obtained within 48 hours to evaluate enlargement of the hematoma. Findings on MR imaging indicating extravasation, including any high-intensity signals on T1-weighted postcontrast images, were observed in 39 patients, and 17 of these also showed evidence of extravasation on cerebral angiography. The presence of extravasation on MR imaging was closely correlated with evidence of hematoma enlargement on follow-up CT scans (p < 0.001). CONCLUSIONS Evidence of extravasation documented on MR imaging indicates persistent hemorrhage and correlates with enlargement of the hematoma.
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Affiliation(s)
- Y Murai
- Department of Neurosurgery, Nippon Medical School and Mejiro General Hospital, Tokyo, Japan
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Takahashi H, Urano T, Nagai N, Takada Y, Takada A. Hyperfibrinolytic activity after head injury is induced by elevated tPA activity. ACTA ACUST UNITED AC 1998. [DOI: 10.1016/s0268-9499(98)80384-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Hypertension commonly occurs in the acute period following spontaneous intracerebral hemorrhage. Management of this hypertension is controversial. Some advocate lowering blood pressure to reduce the risk of bleeding, edema formation, and systemic hypertensive complications, whereas others advocate allowing blood pressure to run its natural course as a protective measure against cerebral ischemia. This article reviews the pertinent clinical and experimental data regarding these issues and briefly discusses the use of antihypertensive agents commonly administered in this setting.
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Affiliation(s)
- R E Adams
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Sherman DG, Dyken ML, Gent M, Harrison JG, Hart RG, Mohr JP. Antithrombotic therapy for cerebrovascular disorders. An update. Chest 1995; 108:444S-456S. [PMID: 7555195 DOI: 10.1378/chest.108.4_supplement.444s] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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