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but the lack of a systematic study of this approach makes it dif cult to endorse without reservation Mechanical lysis of an intra-arterial clot may be as effective Acute Surgical Revascularization Rarely is the patient who has had a stroke brought to medical attention within a few minutes of onset, although this may happen when a patient is in the hospital for another reason If it can be established that the common or internal carotid artery has just become thrombosed, intravenous or preferably intra-arterial t-PA or mechanical lysis of the clot may be effective We have had some experience with immediate surgical removal of the clot or the performance of a bypass to restore function Ojemann and colleagues operated on 55 such patients as an emergency procedure; 26 of these had stenotic vessels and 29 acutely thrombosed vessels Of the latter, circulation was restored in 21, with an excellent or good clinical result in 16 In 26 patients with stenotic carotid arteries, an excellent or good result was obtained in 19 Usually several hours will have elapsed before the diagnosis is established If the interval is longer than 12 h, opening the occluded vessel is usually of little value and may present additional dangers Reoperation after carotid endarterectomy is a special circumstance in which rapid removal of a clot is performed more or less routinely Treatment of Infarctive Cerebral Edema and Raised Intracranial Pressure In the rst few days following massive cerebral infarction, brain edema of the necrotic tissue may threaten life Most often this occurs with a complete infarction in the territory of the middle cerebral artery; some degree of mass effect is evident on a CT scan in the rst 24 h Additional infarction in the territory of the anterior cerebral artery (total carotid occlusion) worsens the situation Clinical deterioration occurs within several days of the stroke (usually worst on the third day, sometimes later) but may evolve as quickly as several hours after the onset (Fig 34-18) The clinical signs of worsening drowsiness, a xed (but not necessarily enlarged) pupil, and a Babinski sign on the side of the infarction are all due to secondary tissue shifts, as described in Chaps 17 and 30 In such instances, controlled hyperventilation may be useful as a temporizing maneuver Frank has shown that clinical deterioration is not always associated with an initial elevation of intracranial pressure It may therefore be advisable, in selected cases, to measure the ICP directly before embarking on an aggressive medical regimen to lower the pressure Intravenous mannitol in doses of 1 g/kg, then 50 g every 2 or 3 h, may forestall further deterioration, but most of these patients, once comatose, are likely to die unless drastic measures are taken Corticosteroids are probably of little value; several trials have failed to demonstrate their ef cacy In the past several years there has been renewed interest in hemicraniectomy as a means of reducing the mass effect and intracranial pressure in these extreme circumstances Our success in salvaging several patients even after a period of coma similar to reported series by Schwab, Carter, Delshaw, and Rengarchary and coworkers indicates that hemicraniectomy combined with an overlying duraplasty may be undertaken if the patient is progressing from a stuporous state to coma and imaging studies show increasing mass effect Of the 63 patients with severe brain swelling and coma in the series of Schwab et al, 46 survived and none remained severely disabled (But there is no question that a number of such patients will remain with hemiplegia) An anterior temporal lobectomy was performed in addition to the craniotomy in some. c# pdf417 open source PDF417 C# Barcode Reader Library - Read PDF-417 in C#.NET ...
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How to generate, create 2d barcode Micro PDF417 images using C# class library. Download .NET Barcode Generator Free Evaluation. Purchase .NET Barcode ... cases, but its effect was not clear The value of surgical decompression has not been limited to patients with right-hemispheric strokes; those with initially limited degrees of aphasia may also be appropriate candidates, but the family must understand the risks involved and the likelihood that the stroke de cits will persist After a protracted period of coma with bilaterally enlarged pupils or with evidence that the midbrain has been irrevocably damaged, the procedure is probably futile but there have been exceptions Many in the eld remain skeptical of these aggressive approaches, and a randomized trial is under way to settle the issue In the special case of large cerebellar infarctions, usually from occlusion of a vertebral artery, swelling may compress the lower brainstem This type of stroke carries the risk of sudden respiratory arrest Hydrocephalus usually develops as a prelude to this event and is manifest as drowsiness and stupor, increased tone in the legs, and Babinski signs; other sentinel signs are gaze paresis, sixth nerve palsy, or hemiparesis ipsilateral to the ataxia (Kanis and Ropper) At times it may be dif cult to differentiate the effects of increasing hydrocephalus from those of a thrombus propagation in the basilar artery (Lehrich et al) Cerebellar swelling may occur with or without an associated lateral medullary stroke The situation is comparable to medullary compression caused by cerebellar hemorrhage (page 715) Surgical decompression of the infarcted and swollen tissue should be undertaken almost as soon as cerebellar edema becomes clinically apparent by the emergence of hydrocephalus or brainstem signs, since further swelling can be anticipated This complication can usually be anticipated in the rst 3 or 4 days after a large cerebellar stroke A brief period of observation before committing to surgery is not unreasonable if the fourth ventricle and peribrainstem cisterns are patent and the patient is awake Mannitol may be used to prepare the patient for surgery or if a period of observation is anticipated As in the case of cerebellar hemorrhage, ventricular drainage alone is usually inadequate and, in any case, is unnecessary if the pressure is relieved by craniectomy and resection of infarcted tissue Anticoagulant Drugs Several considerations weigh in any discussion of the use of anticoagulant treatment of stroke First is the distinction between anticoagulation to prevent the progression of an acute stroke and the prophylactic use of anticoagulation for the prevention of future strokes after the occurrence of TIAs or an initial stroke In the latter instance, the pivotal issue is whether the stroke or TIA is atherothrombotic or cardioembolic As discussed further on, several studies point conclusively to a role for anticoagulation in certain cardioembolic cases, while the indications in atherothrombotic disease are less certain Warfarin and heparin have been used extensively to prevent TIAs and reduce the chances of an impending stroke These anticoagulants may halt the advance of a progressive thrombotic stroke, but they are clearly not effective in all cases and numerous recent studies and position papers have questioned their value altogether (see for example, the Report of the Joint Stroke Guideline Development Committee authored by Coull et al) In deciding whether to use anticoagulants, one faces the question of where in the course of the stroke the patient stands when rst examined One fact seems de nite that the administration of anticoagulants is not of great value once the stroke is fully developed, whether in a patient with a lacunar infarct or one with a massive infarction and hemiplegia It is as yet uncertain whether the long-term use of anticoagulants prevents the recurrence of a thrombotic stroke; in these cases, the incidence of complicating hemorrhage probably outweighs the. free pdf417 generator c# Packages matching Tags:"PDF417" - NuGet Gallery
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