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out any preceding complaint Decerebrate rigidity and brief clonic jerking of the limbs may occur at the onset of the hemorrhage, in association with unconsciousness If the hemorrhage is massive, death may ensue in a matter of minutes or hours, so that ruptured aneurysm must be considered in the differential diagnosis of sudden death A considerable proportion of such patients probably never reach a hospital Persistent deep coma is accompanied by irregular respirations, attacks of extensor rigidity, and nally respiratory arrest and circulatory collapse In these rapidly fatal cases, the subarachnoid blood has greatly increased the intracranial pressure to a level that approaches arterial pressure and caused a marked reduction in cerebral perfusion In some instances the hemorrhage has dissected intracerebrally and entered the ventricular system Rupture of the aneurysm usually occurs while the patient is active rather than during sleep, and in a few instances during sexual intercourse, straining at stool, lifting heavy objects, or other sustained exertion (see page 160) Momentary Valsalva maneuvers, as in coughing or sneezing, have generally not caused aneurysmal rupture (they may cause arterial dissection) In patients who survive the initial rupture, the most feared complication is rerupture, an event that may occur at any time from minutes up to 2 or 3 weeks In less severe cases, consciousness, if lost, may be regained within a few minutes or hours, but a residuum of drowsiness, confusion, and amnesia accompanied by severe headache and stiff neck persists for several days It is not uncommon for the drowsiness and confusion to last 10 days or longer Since the hemorrhage is con ned to the subarachnoid space, there are few if any focal neurologic signs That is to say, gross lateralizing signs in the form of hemiplegia, hemiparesis, homonymous hemianopia, or aphasia are absent in the majority of cases On occasion, a jet of blood emanating from an aneurysm may rupture into the adjacent brain or clot in the insular cistern and produce a hemiparesis or other focal syndrome There may also be a focal syndrome from acute or delayed ischemia in the territory of the aneurysm-bearing artery Usually this occurs several days after a large subarachnoid hemorrhage The pathogenesis of such manifestations is not fully understood, but a transitory fall in pressure in the circulation distal to the aneurysm is postulated in early cases and vasospasm is responsible for the later focal signs Transient de cits are not common, but they do constitute reliable indicators of the site of the ruptured aneurysm (see below) Convulsive seizures, usually brief and generalized, occur in 10 to 25 percent of cases according to Hart et al (but far less often in our experience) in relation to acute bleeding or rebleeding These early seizures do not correlate with the location of the aneurysm and do not appear to alter the prognosis Prior to rupture, saccular aneurysms are usually asymptomatic Exceptionally, if large enough to compress pain-sensitive structures, they may cause localized cranial pain With a cavernous or anterolaterally situated aneurysm on the rst part of the middle cerebral artery, the pain may be projected to the orbit An aneurysm on the posteroinferior or anteroinferior cerebellar artery may cause unilateral occipital or cervical pain The presence of a partial oculomotor palsy with dilated pupil may be indicative of an aneurysm of the posterior communicating internal carotid junction (less often posterior communicating posterior cerebral junction) Occasionally, large aneurysms just anterior to the cavernous sinus may compress the optic nerves or chiasm, third nerve, hypothalamus, or pituitary gland In the cavernous sinus they may compress the third, fourth, or sixth nerve or the ophthalmic division of the fth nerve A monocular visual eld defect may also develop with a. excel 2010 barcode formula IDAutomation 2D Barcode Font for Excel - Free download and ...
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Online Barcode -Generator zum Erstellen und Drucken von Barcodes (EAN13, EAN128, Codabar, Interleaved, etc.), Ausgabeformate JPG, PNG, PDF, Excel ,... supraclinoid aneurysm near the anterior and middle cerebral bifurcation or the ophthalmic-carotid bifurcation Whether a small leak of blood from an aneurysm may serve as a warning sign of rupture ( warning leak ) has been disputed We have seen several cases where an acute and severe exertional or spontaneous headache was found to be associated with a small subarachnoid hemorrhage that was discovered by lumbar puncture; more often the headache is unrelated to hemorrhage and is attributable to migraine This latter thunderclap headache, which may be a variant of migraine, is discussed on page 160 A headache similar to that caused by subarachnoid hemorrhage may also be the re ection of pituitary apoplexy, cerebral venous thrombosis, hypertensive encephalopathy, intracranial hypotension, intracranial arterial dissection, and a condition characterized by diffuse cerebral vasospasm This last entity may be spontaneous or due to the ingestion of sympathomimetic or serotoninergic drugs (see further on, under Diffuse and Focal Cerebral Vasospasm The details of the CSF examination assume great importance in the diagnosis of subarachnoid hemorrhage and the exclusion of the disorders mentioned above Vasospasm Delayed hemiplegia and other focal de cits usually appear 3 to 12 days after rupture and rarely before or after this period These delayed syndromes and the focal narrowing of a large artery or arteries, seen on angiography, are referred to as vasospasm Fisher and coworkers have shown that spasm is most frequent in arteries surrounded by the largest collections of clotted subarachnoid blood The vasospasm appears to be a direct effect of blood or some blood product, possibly hematin or a platelet product, on the adventitia of the artery Areas of ischemic infarction in the territory of the vessel bearing the aneurysm, without thrombosis or other changes in the vessel, is the usual nding in such cases These ischemic lesions are often multiple and occur with great frequency, according to Hijdra and associates (in 57 of 176 prospectively studied patients and a comparable number in large series collected before more modern approaches to treatment became available) After a few days, arteries in chronic spasm undergo a series of morphologic changes The smooth muscle cells of the media become necrotic, and the adventitia is in ltrated with neutrophilic leukocytes, mast cells, and red blood corpuscles, some of which have migrated to a subendothelial position (Chyatte and Sundt) We favor the idea that these changes are caused by products of hemolyzed blood seeping inward from the pia-arachnoid into the muscularis of the artery The clinical features of cerebral vasospasm depend on the affected blood vessel but typically include a uctuating hemiparesis or aphasia and increasing confusion that must be distinguished from the effects of hydrocephalus (see below) In the past, an arteriogram was required to verify the diagnosis, although it is not often performed now because of the slight associated risk of worsening vascular spasm and the ease with which the condition can be recognized by its clinical presentation Severe vasospasm can be visualized with MRA and spinal CT techniques Transcranial Doppler measurements are an indirect and easier way of following, by observations of blood ow velocity, the caliber of the main vessels at the base of the brain Almost all patients have a greatly increased velocity of blood ow in the affected vessel that can be detected by this method in the days after hemorrhage However, progressive elevation of ow velocity in any one vessel (especially if over 175 cm/s) suggests that focal vasospasm is occurring There is a reasonable correlation between these ndings and the radio-. how create barcode in excel 2010 Get Barcode Software - Microsoft Store
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