The Keio journal of medicine
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To formulate treatment strategies for poor-grade patients after aneurysmal subarachnoid hemorrhage (SAH), medical records were analyzed for 166 patients who were in Hunt and Hess Grade IV or V among 588 consecutive cases with ruptured intracranial aneurysm admitted during the past 5 years. Causes of unfavorable outcome (poor or dead) in those 166 patients were evaluated to improve the management outcome. Overall management results of the 166 poor-grade patients were favorable (good or fair) in 71 (42.8%), unfavorable in 95 (78 dead, 17 poor). ⋯ Direct effects of aneurysm rupture (34.8%) and early rebleeding (34.8%) were the major causes of unfavorable outcome in Grade IV patients, while it was direct effect of aneurysm rupture (91.8%) in Grade V patients. It is suggested that as rebleeding is the only preventable cause of unfavorable outcome, urgent management is necessary to prevent rebleeding, especially for Grade IV patients. Grade IV patients should be treated aggressively with direct clipping for non-complex aneurysms or for patients with hematoma, and coil embolization for complex aneurysms without hematoma.
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Review Case Reports
Paramyotonia congenita without cold paralysis: a case report.
A 27-year-old-woman with paramyotonia congenita was reported. She began to suffer from myotonia since infancy. Myotonia was aggravated by cold, but with intense cooling myotonia did not change to flaccid paralysis. ⋯ Paralysis induced by cold is thought to be a feature of paramyotonia congenita, thus raising a possible relationships to hyperkalemic periodic paralysis. In our case cold paralysis never occurred spontaneously and could not be provoked by immersion in ice water or by potassium loading. This finding confirms the existence of paramyotonia congenita without cold paralysis and may provide a nosological distinction between paramyotonia congenita and hyperkalemic periodic paralysis.
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Hypertensive crises constitute a group of distinct clinico-pathological entities in which rapid control of hypertension is indicated to previous serious complications. Although systemic blood pressure is invariably elevated in these conditions, it is the status of the target organ function which determines the need for urgent reduction of blood pressure. The physicians should be cognizant of the pathophysiological basis of hypertensive crises so that rational therapeutic choices can be made. ⋯ Several potent, parentally effective antihypertensive drugs such as nitroprusside, labetalol, and nicardipine are available to produce an immediate fall in blood pressure. The choice of drug therapy should be made on the basis of the pharmacodynamic and clinical effects, advantages, and disadvantages. Once the emergency situation is resolved, the etiology of hypertensive crisis should be considered.