Stroke; a journal of cerebral circulation
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Computed tomography demonstrated acute hydrocephalus less than or equal to 72 hours after subarachnoid hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. ⋯ The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic patients with serial lumbar puncture was not higher than the rate in those without hydrocephalus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage.
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We analyzed the association between hematologic factors and blood velocity of the middle cerebral artery in 42 healthy ambulatory subjects aged 63-86 years. We found a significant inverse association between mean velocity and both hematocrit (r = -0.37, p less than 0.02) and fibrinogen concentration (r = -0.42, p less than 0.005). These two variables are independently associated with velocity and together explain 29% of the variance in mean velocity. Both hematocrit and fibrinogen concentration should be considered in the interpretation of transcranial Doppler findings in this population.
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Moderate hypothermia (30 degrees C) induced before circulatory arrest is known to improve neurologic outcome. We explored, for the first time in a reproducible dog outcome model, moderate hypothermia induced during reperfusion after cardiac arrest (resuscitation). In three groups of six dogs each (N = 18), normothermic ventricular fibrillation cardiac arrest (no blood flow) of 17 minutes was reversed by cardiopulmonary bypass--normothermic in control group I (37.5 degrees C) and hypothermic to 3 hours in groups II (32 degrees C) and III (28 degrees C). ⋯ Mean +/- SD brain total histologic damage score was 130 +/- 22 in group I, 93 +/- 28 in group II (p = 0.05), and 80 +/- 26 in group III (p = 0.03). Gross myocardial damage was greater in groups II and III than in group I--numerically higher overall and significantly higher in group III for the right ventricle alone (p = 0.02). Moderate hypothermia after prolonged cardiac arrest may or may not improve cerebral outcome slightly and can worsen myocardial damage.
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Using positron emission tomography in nine patients with minor strokes, unilateral internal carotid artery occlusion, and good collateral circulation through the anterior portion of the circle of Willis, we analyzed regional cerebral blood flow, cerebral metabolic rate of oxygen, oxygen extraction fraction, and cerebral blood volume. These studies allowed quantification of the regional hemodynamic status, especially in relation to watershed areas. Compared with eight normal controls, the patients had significantly (p less than 0.01) decreased regional cerebral blood flow in the middle cerebral artery territory and the surrounding watershed areas of the occluded hemisphere. ⋯ A concomitant decrease in the cerebral blood flow/cerebral blood volume ratio suggested reduction in the mean blood flow velocity, whereby elevated blood viscosity would be more liable to reduce cerebral blood flow. These findings suggest hemodynamic vulnerability of the watershed areas after internal carotid artery occlusion in persons with good collateral circulation through the anterior portion of the circle of Willis. Our results also emphasize the importance of systemic hemodynamic factors such as blood pressure and circulating blood volume in the genesis of watershed infarction.
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Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. ⋯ The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.