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blood pressure to diminish over several days; therefore active treatment in the acute stages has been a matter of controversy Rapid reduction in blood pressure, in the hope of reducing further bleeding, is not recommended, since it risks compromising cerebral perfusion in cases of raised intracranial pressure On the other hand, sustained mean blood pressures of greater than 110 mmHg may exaggerate cerebral edema and risk extension of the clot It is at approximately this level of acute hypertension that the use of betablocking drugs (esmolol, labetalol) or angiotensin-converting enzyme (ACE) inhibitors is recommended The major calcium channel blocking drugs are used less often for this purpose because of reports of adverse effects on intracranial pressure, although this information derives mainly from patients with brain tumors Hayashi and associates have shown that blood pressure is lowered with nifedipine after cerebral hemorrhage, but intracranial pressure is raised, resulting in an unfavorable net reduction in cerebral perfusion pressure We have, nevertheless, used this class of medication in patients with small and medium-sized clots without adverse effects Diuretics are helpful in combination with any of the antihypertensive medications More rapidly acting and titratable agents such as nitroprusside may be used in extreme situations, recognizing that they may further raise intracranial pressure Surgical evacuation of a hemispheral clot in the acute stage may occasionally be lifesaving, and we have referred numerous patients for surgical treatment when hemispheral hemorrhages were larger than 3 cm in diameter and the clinical state was deteriorating The most successful surgical results have been in patients with lobar or moderate-sized putaminal hemorrhages Although selected patients may be saved from progression to brain death, the focal neurologic de cit is not altered Even this modest result requires that operation be carried out before or very soon after coma supervenes But, on the basis of numerous small studies, it must be stated that surgical results have generally not been superior to those with medical measures alone (Waga and Yamamato, Batjer et al, Juvela et al; Rabinstein et al) It would appear intuitively that the removal of an acutely formed clot from the cerebral hemispheres should be greatly bene cial, but it has been dif cult to demonstrate this effect in various groups of patients Once the patient becomes deeply comatose with dilated xed pupils, the chance of any recovery is negligible In part, disappointing results have been the result of combining patients in various stages of stupor and coma, undoubtedly with different levels of intracranial pressure and clots of various sizes and locations Even in organized (if retrospective) studies in which clinical worsening was the reason for surgery, such as the one by Rabinstein and colleagues, only one-quarter of patients attained a state of functional independence All of their patients who lost their brainstem re exes and had extensor posturing died despite surgery; there are few exceptions to this observation In comatose patients with large hemorrhages, we have found that the placement of a device for constant monitoring of intracranial pressure enables the clinician to use medical measures with greater precision, as outlined in Chap 17, but there is no evidence that outcome is signi cantly improved (Ropper and King) Whether hemicraniectomy is of value, as it is with large hemispheral strokes, is not known In contrast, the surgical evacuation of cerebellar hematomas is a generally accepted treatment and is a more urgent matter because of the proximity of the mass to the brainstem and the risk of abrupt progression to coma and respiratory failure Also, hydrocephalus from compression of the fourth ventricle more often complicates the clinical picture and further raises intracranial pressure.

is the assignment of the data provider, shown at the top of the dialog box in the following illustration So, we have two locations where we can set the data provider: in the Data Provider field of Step 1 or in Step 2 by accessing the Edit Web Item dialog box via the Define New Chart Item Button A third option is to go directly into the Web item and set the data provider

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(St Louis et al) As a rule, a cerebellar hematoma of less than 2 cm in diameter leaves most patients awake and infrequently leads to deterioration, therefore not requiring surgery Hematomas that are 4 cm or more in largest diameter, especially if located in the vermis, pose the greatest risk, and some surgeons have recommended evacuation of lesions of this size no matter what the clinical status of the patient In determining the need for surgical evacuation, we have been guided by the state of consciousness, the mass effect caused by the clot as visualized on CT scan (particularly the degree of compression of the quadrigeminal cistern, as pointed out by Taneda and colleagues), and the presence of hydrocephalus Often this requires daily or even more frequent CT scans The patient who is stuporous or displays arrhythmic breathing is best intubated and brought to the operating room within hours or sooner Once coma and pupillary changes supervene, few patients survive, even with surgery; however, rapid medical intervention with mannitol and hyperventilation, followed by surgical evacuation of the clot and drainage of the ventricles very soon after the onset of coma, has been successful in a few cases Patients who are only drowsy and those with hematomas of 2 to 4 cm in diameter pose the greatest dif culty in deciding about surgery If the level of consciousness is uctuating or if there is obliteration of the perimesencephalic cisterns, particularly if coupled with hydrocephalus, we believe that the risk of surgery is less than that of a sudden deterioration In only a very limited number of patients have we found it practical to perform only drainage of the enlarged ventricles, although some groups still favor this procedure and eschew a posterior fossa operation In our experience, evacuation of the clot has been more important than reduction of hydrocephalus.

Managed performance versus indexed performance has been a hot topic lately In many cases the indexed portfolios have outperformed the managed portfolio, and now it seems that every manager s goal is to beat the index It is a tough call on this, but in general over the long haul common sense would dictate that the best advice is to diversify Use some of both There will be times when managed funds far exceed the indices when the market struggles to recover from economic slowdowns Not all managers are equal, and certainly the more aggressive the manager, the more risk and the more potential for reward Index products such as index ETFs are excellent tools and should be utilized thoroughly, but having a manager to assess risk in choppy times will likely be bene cial We have all been a bit spoiled, and there are a number of young traders who don t remember much of an S&P 500 at 300 chopping around for two years to recover from the 1987 crash, much less further back We have been spoiled by the volatility in the market and are relying on years of index growth that is not likely to not occur in negative or at GDP The S&P lost nearly 40 percent, and at an average 10 percent annual rate of return in the S&P, will it take four years to recover Probably not, but there is a decent chance that the managed portfolio will surpass the indexed portfolio

Spontaneous Subarachnoid Hemorrhage (Ruptured Saccular Aneurysm)

This is the fourth most frequent cerebrovascular disorder following atherothrombosis, embolism, and primary intracerebral hemAnt communicating A

The results of these minor changes and adjustments are shown in the following illustration So, within about 10 to 15 minutes, your business users can have something to review and base suggestions on This is a decent-looking chart, though far from the best look and feel that we can achieve The heading is well displayed, the graphics are direct and

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