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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. random barcode generator excel Barcode Add -In for Word & Excel Download and Installation
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