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Treatment of Stroke

  • Douglas J. Cook
  • Michael TymianskiEmail author
Chapter

Abstract

Stroke is defined by the World Health Organization (WHO) as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 h or longer or leading to death, with no apparent cause other than that of vascular origin” [1]. Therefore, stroke may be the result of an ischemic or hemorrhagic etiology. In either case there is a “core” area of immediate cell death related to the primary insult surrounded by a zone of viable but at-risk tissue. In the case of ischemic stroke the core is defined as a severely hypoperfused region with blood flow estimated to be less than 8 mL/100 g tissue/min [2]. The core is surrounded by a zone of tissue that suffers from critically low blood flow estimated to be between 8 and 20 mL/100 g tissue/min known as the “penumbra.” With continued ischemia the penumbra goes on to die [2]. In the case of hemorrhagic stroke, the core area comprises tissue that is destroyed immediately by shear force and mass effect relating to the hemorrhage [3]. The surrounding tissue probably does not have impaired blood flow as in ischemic stroke [4], but is at risk of further damage if the hematoma expands or re-bleeds and creates further shear force or mass effect [5].

Keywords

Acute Ischemic Stroke Stroke Onset Decompressive Craniectomy American Heart Association Guideline Basilar Artery Occlusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Thorvaldsen P, Asplund K, Kuulasmaa K, Rajakangas AM, Schroll M. Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease. Stroke. 1995;26(3):361–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Baron JC. Perfusion thresholds in human cerebral ischemia: historical perspective and therapeutic implications. Cerebrovasc Dis. 2001;11 Suppl 1:2–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Mayer SA, Rincon F. Treatment of intracerebral haemorrhage. Lancet Neurol. 2005;4(10):662–72.PubMedCrossRefGoogle Scholar
  4. 4.
    Zaleska MM, Mercado ML, Chavez J, Feuerstein GZ, Pangalos MN, Wood A. The development of stroke therapeutics: promising mechanisms and translational challenges. Neuropharmacology. 2009;56(2):329–41.PubMedCrossRefGoogle Scholar
  5. 5.
    Davis SM, Broderick J, Hennerici M, Brun NC, Diringer MN, Mayer SA, et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006;66(8):1175–81.PubMedCrossRefGoogle Scholar
  6. 6.
    van der Worp HB, van Gijn J. Clinical practice. Acute ischemic stroke. N Engl J Med. 2007;357(6):572–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Saver JL. Time is brain–quantified. Stroke. 2006;37(1):263–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Adams Jr HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(5):1655–711.PubMedCrossRefGoogle Scholar
  9. 9.
    Hilker R, Poetter C, Findeisen N, Sobesky J, Jacobs A, Neveling M, et al. Nosocomial pneumonia after acute stroke: implications for neurological intensive care medicine. Stroke. 2003;34(4):975–81.PubMedCrossRefGoogle Scholar
  10. 10.
    Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA; IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002;33(5):1315–20.Google Scholar
  11. 11.
    Stead LG, Gilmore RM, Decker WW, Weaver AL, Brown Jr RD. Initial emergency department blood pressure as predictor of survival after acute ischemic stroke. Neurology. 2005;65(8):1179–83.PubMedCrossRefGoogle Scholar
  12. 12.
    Tanne D, Kasner SE, Demchuk AM, Koren-Morag N, Hanson S, Grond M, et al. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survey. Circulation. 2002;105(14):1679–85.PubMedCrossRefGoogle Scholar
  13. 13.
    Markus HS. Cerebral perfusion and stroke. J Neurol Neurosurg Psychiatry. 2004;75(3):353–61.PubMedCrossRefGoogle Scholar
  14. 14.
    Greer DM, Funk SE, Reaven NL, Ouzounelli M, Uman GC. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke. 2008;39(11):3029–35.PubMedCrossRefGoogle Scholar
  15. 15.
    Hemmen TM, Lyden PD. Induced hypothermia for acute stroke. Stroke. 2007;38(2 Suppl):794–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Malouf R, Brust JC. Hypoglycemia: causes, neurological manifestations, and outcome. Ann Neurol. 1985;17(5):421–30.PubMedCrossRefGoogle Scholar
  17. 17.
    Yong M, Kaste M. Dynamic of hyperglycemia as a predictor of stroke outcome in the ECASS-II trial. Stroke. 2008;39(10):2749–55.PubMedCrossRefGoogle Scholar
  18. 18.
    Wintermark M, Reichhart M, Cuisenaire O, Maeder P, Thiran JP, Schnyder P, et al. Comparison of admission perfusion computed tomography and qualitative diffusion- and perfusion-weighted magnetic resonance imaging in acute stroke patients. Stroke. 2002;33(8):2025–31.PubMedCrossRefGoogle Scholar
  19. 19.
    Chalela JA, Alsop DC, Gonzalez-Atavales JB, Maldjian JA, Kasner SE, Detre JA. Magnetic resonance perfusion imaging in acute ischemic stroke using continuous arterial spin labeling. Stroke. 2000;31(3):680–7.PubMedCrossRefGoogle Scholar
  20. 20.
    NINDS tSTSG. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333(24):1581–7.CrossRefGoogle Scholar
  21. 21.
    Kwiatkowski TG, Libman RB, Frankel M, Tilley BC, Morgenstern LB, Lu M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med. 1999;340(23):1781–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al.; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–29.Google Scholar
  23. 23.
    Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M, et al.; DIAS Study Group. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke. 2005;36(1):66–73.Google Scholar
  24. 24.
    Tanswell P, Modi N, Combs D, Danays T. Pharmacokinetics and pharmacodynamics of tenecteplase in fibrinolytic therapy of acute myocardial infarction. Clin Pharmacokinet. 2002;41(15):1229–45.PubMedCrossRefGoogle Scholar
  25. 25.
    Haley EC Jr, Lyden PD, Johnston KC, Hemmen TM; TNK in Stroke Investigators. A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Stroke. 2005;36(3):607–12.Google Scholar
  26. 26.
    Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282(21):2003–11.PubMedCrossRefGoogle Scholar
  27. 27.
    Ogawa A, Mori E, Minematsu K, Taki W, Takahashi A, Nemoto S, et al.; MELT Japan Study Group. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (MELT) Japan. Stroke. 2007;38(10):2633–39.Google Scholar
  28. 28.
    Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P; American College of Chest Physicians. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):630S–69S.Google Scholar
  29. 29.
    Burns TC, Rodriguez GJ, Patel S, Hussein HM, Georgiadis AL, Lakshminarayan K, et al. Endovascular interventions following intravenous thrombolysis may improve survival and recovery in patients with acute ischemic stroke: a case–control study. AJNR Am J Neuroradiol. 2008;29(10):1918–24.PubMedCrossRefGoogle Scholar
  30. 30.
    IMS II Trial Investigators. The Interventional Management of Stroke (IMS) II Study. Stroke. 2007;38(7):2127–35.CrossRefGoogle Scholar
  31. 31.
    Flaherty ML, Woo D, Kissela B, Jauch E, Pancioli A, Carrozzella J, et al. Combined IV and intra-arterial thrombolysis for acute ischemic stroke. Neurology. 2005;64(2):386–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Lee KY, Kim DI, Kim SH, Lee SI, Chung HW, Shim YW, et al. Sequential combination of intravenous recombinant tissue plasminogen activator and intra-arterial urokinase in acute ischemic stroke. AJNR Am J Neuroradiol. 2004;25(9):1470–5.PubMedGoogle Scholar
  33. 33.
    Shaltoni HM, Albright KC, Gonzales NR, Weir RU, Khaja AM, Sugg RM, et al. Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke? Stroke. 2007;38(1):80–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Kim DJ, Kim DI, Kim SH, Lee KY, Heo JH, Han SW. Rescue localized intra-arterial thrombolysis for hyperacute MCA ischemic stroke patients after early non-responsive intravenous tissue plasminogen activator therapy. Neuroradiology. 2005;47(8):616–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Stead LG, Gilmore RM, Bellolio MF, Rabinstein AA, Decker WW. Percutaneous clot removal devices in acute ischemic stroke: a systematic review and meta-analysis. Arch Neurol. 2008;65(8):1024–30.PubMedCrossRefGoogle Scholar
  36. 36.
    Leary MC, Saver JL, Gobin YP, Jahan R, Duckwiler GR, Vinuela F, et al. Beyond tissue plasminogen activator: mechanical intervention in acute stroke. Ann Emerg Med. 2003;41(6):838–46.PubMedCrossRefGoogle Scholar
  37. 37.
    Levy EI, Ecker RD, Horowitz MB, Gupta R, Hanel RA, Sauvageau E, et al. Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery. 2006;58(3):458–63. discussion 458–463.PubMedGoogle Scholar
  38. 38.
    Nogueira RG, Schwamm LH, Hirsch JA. Endovascular approaches to acute stroke, part 1: drugs, devices, and data. AJNR Am J Neuroradiol. 2009;30(4):649–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol. 2006;27(6):1177–82.PubMedGoogle Scholar
  40. 40.
    Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al.; Multi MERCI Investigators. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39(4):1205–12.Google Scholar
  41. 41.
    Zeumer H, Ringelstein EB, Hacke W. [Vascular recanalization procedure in interventional neuroradiology]. Rofo. 1983;139(5):467–75.PubMedCrossRefGoogle Scholar
  42. 42.
    Hacke W, Zeumer H, Ferbert A, Brückmann H, del Zoppo GJ. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19(10):1216–22.PubMedCrossRefGoogle Scholar
  43. 43.
    Jung S, Mono ML, Fischer U, Galimanis A, Findling O, De Marchis GM, et al. Three-month and long-term outcomes and their predictors in acute basilar artery occlusion treated with intra-arterial thrombolysis. Stroke. 2011;42(7):1946–51.PubMedCrossRefGoogle Scholar
  44. 44.
    Bergui M, Stura G, Daniele D, Cerrato P, Berardino M, Bradac GB. Mechanical thrombolysis in ischemic stroke attributable to basilar artery occlusion as first-line treatment. Stroke. 2006;37(1):145–50.PubMedCrossRefGoogle Scholar
  45. 45.
    Xavier AR, Tiwari A, Purai N, Rayes M, Pandey P, Kansara A, et al. Safety and efficacy of intracranial stenting for acute ischemic stroke beyond 8 h of symptom onset. J Neurointerv Surg. 2012;4(2):94–100.PubMedCrossRefGoogle Scholar
  46. 46.
    Lutsep HL, Rymer MM, Nesbit GM. Vertebrobasilar revascularization rates and outcomes in the MERCI and multi-MERCI trials. J Stroke Cerebrovasc Dis. 2008;17(2):55–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Hacke W, Schwab S, Horn M, Spranger M, De Georgia M, von Kummer R. ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309–15.PubMedCrossRefGoogle Scholar
  48. 48.
    Walz B, Zimmermann C, Böttger S, Haberl RL. Prognosis of patients after hemicraniectomy in malignant middle cerebral artery infarction. J Neurol. 2002;249(9):1183–90.PubMedCrossRefGoogle Scholar
  49. 49.
    Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al.; DECIMAL Investigators. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38(9):2506–17.Google Scholar
  50. 50.
    Gupta R, Connolly ES, Mayer S, Elkind MS. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35(2):539–43.PubMedCrossRefGoogle Scholar
  51. 51.
    Carter BS, Ogilvy CS, Candia GJ, Rosas HD, Buonanno F. One-year outcome after decompressive surgery for massive nondominant hemispheric infarction. Neurosurgery. 1997;40(6):1168–75. discussion 1175–1166.PubMedCrossRefGoogle Scholar
  52. 52.
    Leonhardt G, Wilhelm H, Doerfler A, Ehrenfeld CE, Schoch B, Rauhut F, et al. Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction. J Neurol. 2002;249(10):1433–40.PubMedCrossRefGoogle Scholar
  53. 53.
    Chen HJ, Lee TC, Wei CP. Treatment of cerebellar infarction by decompressive suboccipital craniectomy. Stroke. 1992;23(7):957–61.PubMedCrossRefGoogle Scholar
  54. 54.
    Schellinger PD, Fiebach JB, Hoffmann K, Becker K, Orakcioglu B, Kollmar R, et al. Stroke MRI in intracerebral hemorrhage: is there a perihemorrhagic penumbra? Stroke. 2003;34(7):1674–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Macdonald RL, Pluta RM, Zhang JH. Cerebral vasospasm after subarachnoid hemorrhage: the emerging revolution. Nat Clin Pract Neurol. 2007;3(5):256–63.PubMedCrossRefGoogle Scholar
  56. 56.
    Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med. 1999;27(3):617–21.PubMedCrossRefGoogle Scholar
  57. 57.
    Bhattathiri PS, Gregson B, Prasad KS, Mendelow AD; STICH Investigators. Intraventricular hemorrhage and hydrocephalus after spontaneous intracerebral hemorrhage: results from the STICH trial. Acta Neurochir Suppl. 2006;96:65–8.Google Scholar
  58. 58.
    Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update—a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38(6):2001–23.PubMedCrossRefGoogle Scholar
  59. 59.
    Lubetsky A, Hoffman R, Zimlichman R, Eldor A, Zvi J, Kostenko V, et al. Efficacy and safety of a prothrombin complex concentrate (Octaplex) for rapid reversal of oral anticoagulation. Thromb Res. 2004;113(6):371–8.PubMedCrossRefGoogle Scholar
  60. 60.
    Creutzfeldt CJ, Weinstein JR, Longstreth Jr WT, Becker KJ, McPharlin TO, Tirschwell DL. Prior antiplatelet therapy, platelet infusion therapy, and outcome after intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2009;18(3):221–8.PubMedCrossRefGoogle Scholar
  61. 61.
    Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al.; FAST Trial Investigators. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008;358(20):2127–37.Google Scholar
  62. 62.
    Rabinstein AA, Atkinson JL, Wijdicks EF. Emergency craniotomy in patients worsening due to expanded cerebral hematoma: to what purpose? Neurology. 2002;58(9):1367–72.PubMedCrossRefGoogle Scholar
  63. 63.
    Kuo LT, Chen CM, Li CH, Tsai JC, Chiu HC, Liu LC, et al. Early endoscope-assisted hematoma evacuation in patients with supratentorial intracerebral hemorrhage: case selection, surgical technique, and long-term results. Neurosurg Focus. 2011;30(4):E9.PubMedCrossRefGoogle Scholar
  64. 64.
    Zhou H, Zhang Y, Liu L, Han X, Tao Y, Tang Y, et al. A prospective controlled study: minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage. BMC Neurol. 2011;11:76.PubMedCrossRefGoogle Scholar
  65. 65.
    Zhou H, Zhang Y, Liu L, Huang Y, Tang Y, Su J, et al. Minimally invasive stereotactic puncture and thrombolysis therapy improves long-term outcome after acute intracerebral hemorrhage. J Neurol. 2011;258(4):661–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Carhuapoma JR, Barrett RJ, Keyl PM, Hanley DF, Johnson RR. Stereotactic aspiration-thrombolysis of intracerebral hemorrhage and its impact on perihematoma brain edema. Neurocrit Care. 2008;8(3):322–9.PubMedCrossRefGoogle Scholar
  67. 67.
    Umebayashi D, Mandai A, Osaka Y, Nakahara Y, Tenjin H. Effects and complications of stereotactic aspiration for spontaneous intracerebral hemorrhage. Neurol Med Chir (Tokyo). 2010;50(7):538–44.PubMedCrossRefGoogle Scholar
  68. 68.
    Morgenstern LB, Demchuk AM, Kim DH, Frankowski RF, Grotta JC. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology. 2001;56(10):1294–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Zuccarello M, Brott T, Derex L, Kothari R, Sauerbeck L, Tew J, et al. Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke. 1999;30(9):1833–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Tan SH, Ng PY, Yeo TT, Wong SH, Ong PL, Venketasubramanian N. Hypertensive basal ganglia hemorrhage: a prospective study comparing surgical and nonsurgical management. Surg Neurol. 2001;56(5):287–92. discussion 292–283.PubMedCrossRefGoogle Scholar
  71. 71.
    Juvela S, Heiskanen O, Poranen A, Valtonen S, Kuurne T, Kaste M, et al. The treatment of spontaneous intracerebral hemorrhage. A prospective randomized trial of surgical and conservative treatment. J Neurosurg. 1989;70(5):755–8.PubMedCrossRefGoogle Scholar
  72. 72.
    Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365(9457):387–97.PubMedGoogle Scholar
  73. 73.
    Gregson BA, Broderick JP, Auer LM, Batjer H, Chen XC, Juvela S, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke. 2012;43:1496–504.PubMedCrossRefGoogle Scholar
  74. 74.
    Inagawa T, Ohbayashi N, Takechi A, Shibukawa M, Yahara K. Primary intracerebral hemorrhage in Izumo City, Japan: incidence rates and outcome in relation to the site of hemorrhage. Neurosurgery. 2003;53(6):1283–97. discussion 1297–1288.PubMedCrossRefGoogle Scholar
  75. 75.
    Da Pian R, Bazzan A, Pasqualin A. Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurol Res. 1984;6(3):145–51.PubMedGoogle Scholar
  76. 76.
    Barbato G, Moul DE, Schwartz P, Rosenthal NE, Oren DA. Spontaneous eye blink rate in winter seasonal affective disorder. Psychiatry Res. 1993;47(1):79–85.PubMedCrossRefGoogle Scholar
  77. 77.
    Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery. 2001;49(6):1378–86. discussion 1386–1377.PubMedCrossRefGoogle Scholar
  78. 78.
    Cohen ZR, Ram Z, Knoller N, Peles E, Hadani M. Management and outcome of non-traumatic cerebellar haemorrhage. Cerebrovasc Dis. 2002;14(3–4):207–13.PubMedCrossRefGoogle Scholar
  79. 79.
    Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage–surgical or conservative management? Neurosurgery. 1994;34(2):246–50. discussion 250–241.PubMedCrossRefGoogle Scholar
  80. 80.
    Luparello V, Canavero S. Treatment of hypertensive cerebellar hemorrhage–surgical or conservative management? Neurosurgery. 1995;37(3):552–3.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of NeurosurgeryLucile Packard Children’s Hospital, Stanford Hospital and ClinicsStanfordUSA
  2. 2.Department of NeurosurgeryToronto Western HospitalTorontoCanada

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