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December 10, 1982, Vol 248, No. 22 >
ARTICLE | December 10, 1982

Observations During Hypervolemic Hemodilution of Patients With Acute Focal Cerebral Ischemia FREE

James H. Wood, MD; Alan S. Fleischer, MD
[+] Author Affiliations

Reprint requests to Division of Neurosurgery, Emory University Clinic, 1365 Clifton Rd NE, Atlanta, GA 30322 (Dr Wood).


JAMA. 1982;248(22):2999-3004. doi:10.1001/jama.1982.03330220043034
Text Size: A A A
Published online
Article
References

Infusions of 5% albumin and/or dextran 40 in nine patients with acute ischemic neurological deficits reduced mean hematocrit values from 41% to 32%, raised mean central venous pressure from 4 to 12 cm H2O, and reduced mean arterial BP from 101 to 94 mm Hg. Six alert patients had ischemic structural damage on cranial computed tomography. All six alert patients with upper arm paresis objectively improved and two others with only dysphasia also improved within 24 hours after infusion initiation. Although the improvement in two patients seemed to be temporarily dependent on the continuing of the infusion, all eight alert patients were eventually weaned without loss of regained function. This report of neurological improvement during hypervolemic hemodilution suggests that augmentation of collateral perfusion secondary to reduced blood viscosity may rapidly relieve cerebral ischemia, impede infarction, and allow time for compensatory mechanisms to maintain blood flow above ischemic thresholds.

(JAMA 1982;248:2999-3004)

REFERENCES

1 +
McMurtry JG, Pool JL, Nova HR:  The use of Rheomacrodex in the surgery of intracranial aneurysms . J Neurosurg 1967;;26:218-222.
2 +
Kosnik EJ, Hunt WE:  Postoperative hypertension in the management of patients with intracranial aneurysms . J Neurosurg 1976;; 45:148-154.
3 +
Giannotta SL, McGillicuddy JE, Kindt GW:  Diagnosis and treatment of postoperative cerebral vasospasm . Surg Neurol 1977;;8:286-290.
4 +
Printz MB, Giannotta SL, Kindt GW, et al:  Treatment of patients with neurological deficits associated with cerebral vasospasm by intravascular volume expansion . Neurosurgery 1978;; 3:364-368.
5 +
Giannotta SL, Kindt GW:  Total morbidity and mortality rates in patients with surgically treated intracranial aneurysms . Neurosurgery 1979;;4:125-128.
6 +
Maroon JC, Nelson PB:  Hypovolemia in patients with subarachnoid hemorrhage: Therapeutic implications . Neurosurgery 1979;;4:223-225.
7 +
Sundt TM Jr:  Editorial comments of reference 6 . Neurosurgery 1979;;4:225.
8 +
Fleischer AD, Tindall GT:  Cerebral vasospasm following aneurysm rupture: A protocol for therapy and prophylaxis . J Neurosurg 1980;; 52:149-152.
9 +
Kudo T, Suzuki S, Iwabuchi T:  Importance of monitoring the circulating blood volume in patients with cerebral vasospasm after subarachnoid hemorrhage . Neurosurgery 1981;; 9:514-520.
10 +
Giannotta SL, McGillicuddy JE, Kindt GW:  Gradual carotid artery occlusion in the treatment of inaccessible internal carotid artery aneurysms . Neurosurgery 1979;;5:417-420.
11 +
Pritz MB:  Cardiopulmonary monitoring during graded cervical internal carotid artery occlusion. Physiological results and therapeutic implications . Neurosurgery 1980;;8:520-524.
12 +
Farhat SM, Schneider RC:  Observations on the effect of systemic blood pressure on intracranial circulation in patients with cerebrovascular insufficiency . J Neurosurg 1967;;27:441-445.
13 +
De Aranjo LC, Zappula RA, Yang WC, et al:  Angiographic changes to induced hypertension in cerebral vasospasm: Case report . J Neurosurg 1978;;49:312-315.
14 +
Montgomery EB, Grubb RL, Raichle ME:  Cerebral hemodynamics and metabolism in postoperative cerebral vasospasm and treatment with hypertensive therapy . Ann Neurol 1981;; 9:502-506.
15 +
Gilroy J, Barnhart MI, Meyer JS:  Treatment of acute stroke with dextran 40 . JAMA 1969;;210:293-298.
16 +
Heiss W-D, Prosenz P, Tschabitscher H, et al:  Effect of low-molecular dextran on total cerebral blood flow and on regional flow within ischemic brain lesions . Eur Neurol 1972;;8:129-133.
17 +
Gottstein U, Sedlmeyer I, Heuss A:  Treatment of acute cerebral ischemia with low-molecular dextran: Results of a retrospective study . Dtsch Med Wochenschr 1976;;101:223-227.
18 +
Kaste M, Fogelholm R, Waltimo O:  Combined dexamethasone and low-molecular-weight dextran in acute brain infarction: Double-blind study . Br Med J 1976;;2:1409-1410.
19 +
Matthews WB, Oxburg JM, Grainger KMR, et al:  A blind controlled trial of dextran-40 in the treatment of ischaemic stroke . Brain 1976;;99:193-206.
20 +
Eisenberg S:  Blood viscosity and fibrinogen concentration following cerebral infarction . Circulation 1966;;33-34( (suppl 2) ):10-14.
21 +
Ott EO, Lechner H, Aranibar A:  High blood viscosity syndrome in cerebral infarction . Stroke 1974;;5:330-333.
22 +
Harrison MJG, Pollack S, Kendall BE, et al:  Effect of haematocrit on carotid stenosis and cerebral infarction . Lancet 1981;;2:114-115.
23 +
Thomas DJ, duBoulay GM, Marshall J, et al:  Effect of haematocrit on cerebral blood flow in man . Lancet 1977;;2:941-943.
24 +
DeWeese JA, May AG, Lipchik EO, et al:  Anatomic and hemodynamics correlations in carotid artery stenosis . Stroke 1970;;1:149-157.
25 +
DeLong RN: The Neurologic Examination , ed 4. Hagerstown, Md, Harper & Row Publishers Inc, 1979;, p 338.
26 +
Hint H:  The pharmacology of dextran and the physiological background for the clinical use of Rheomacrodex and Macrodex . Acta Anaesthesiol Belg 1968;;19:119-138.
27 +
Czer LSB, Shoemaker WC:  Optimal hematocrit value in critically ill postoperative patients . Surg Gynecol Obstet 1978;;147:363-368.
28 +
Huntsberger DV, Leaverton PE: Statistical Inference in the Biomedical Sciences . Boston, Allyn & Bacon Inc, 1970;, pp 133, 135-136.
29 +
Jones TH, Morawetz RB, Crowell RM, et al:  Thresholds of focal cerebral ischemia in awake monkeys . J Neurosurg 1981;;54:773-782.
30 +
Crowell RM, Marcoux FW, DeGirolami U:  Variability and reversibility of focal cerebral ischemia in unanesthetized monkeys . Neurology 1981;;31:1295-1302.
31 +
Takagi S, Shinohara Y:  Internal carotid occlusion: Volume of cerebral infarction, clinical findings and prognosis . Stroke 1981;;12:835-839.
32 +
Kogure K, Busto R, Scheinberg P:  The role of hydrostatic pressure in ischemic brain edema . Ann Neurol 1981;;9:273-282.
33 +
Cook P, James I:  Cerebral vasodilators, part 1 . N Engl J Med 1981;;305:1508-1513.
34 +
Cook P, James I:  Cerebral vasodilators, part 2 . N Engl J Med 1981;;305:1560-1564.
35 +
Wood JH, Simeone FA, Snyder LL, et al:  Hemodilutional and nonhemodilutional hypervolemia in treatment of focal cerebral ischemia . J CBF Metabol 1981;;1( (suppl 1) ):S178-S179.
36 +
Wood JH, Snyder LL, Simeone FA, et al:  Cerebrovascular and cardiac responses to intravascular volume expansion following focal cerebral ischemia , abstracted. Stroke 1981;;12:130.
37 +
Wood JH, Simeone FA, Snyder LL, et al:  Treatment of experimental focal ischemia with intravascular volume expansion . Neurology 1981;; 32(a):153.
38 +
Wood JH, Simeone FA, Fink EA, et al:  Hypervolemic hemodilution in experimental focal cerebral ischemia: Elevation of cardiac output, regional cortical blood flow and intracranial pressure following low-molecular-weight dextran infusions . J Neurosurg , in press.
39 +
Gottstein U:  Cerebral blood flow, CMRO2 and CMR of glucose in patients with hypo and hyperchromatic anemia and polycythemia: The effect of hemodilution on CBF, CMR and hematocrit , in Meyer JS, Lechner H, Reivich M (eds): Cerebral Vascular Disease . New York, Elsevier North Holland Inc, 1979;, vol 2, pp 225-229.
40 +
Henriksen L, Paulson OB, Smith RM:  Cerebral blood flow following normovolemic hemodilution in patients with high hematocrit . Ann Neurol 1981;;9:454-457.
41 +
Pollock S, Tsitsopoulos P, Harrison MJG:  The effect of hematocrit on cerebral perfusion and clinical status following carotid occlusion in the gerbil . Stroke 1982;;13:167-170.
42 +
Wood JH, Simeone FA, Kron RE, et al:  Rheologic aspects of experimental hypervolemic hemodilution with low-molecular-weight dextran: Relationships of corticol blood flow, cardiac output and intracranial pressure to fresh blood viscosity and plasma volume . Neurosurgery , in press.
43 +
Kinkel WR, Jacobs L:  Computerized axial transverse tomography in cerebrovascular disease . Neurology 1976;;26:924-930.
44 +
Wing SD, Norman D, Pollock JA, et al:  Contrast enhancement of cerebral infarcts in computed tomography . Radiology 1976;;121:89-92.
45 +
Norton GA, Kishore PRS, Lin J:  CT contrast enhancement in cerebral infarction . AJR 1978;;131:881-885.
46 +
Masden JC, Azar-Kia B, Rubino FA:  Evaluation of recent cerebral infarction by computerized tomography . Arch Neurol 1977;;34:417-421.
47 +
Alcala H, Gado M, Torack RM:  The effect of size, histologic elements, and water content on the visualization of cerebral infarcts: A computerized cranial tomographic study . Arch Neurol 1978;;35:1-7.
48 +
Wood JH, Snyder LL, Simeone FA:  Failure of intravascular volume expansion without hemodilution to elevate cortical blood flow in region of experimental focal ischemia . J Neurosurg 1982;;56:80-91.
49 +
Wood JH, Simeone FA, Kron RE, et al:  Relationship of cortical blood flow and cardiovascular responses to alteration in fresh blood viscosity as determined by capillary stepresponse viscometry . J CBF Metabol 1981;; 1( (suppl 1) ):S233-S234.
50 +
Wood JH, Simeone FA, Kron RE, et al:  Correlation of cortical blood flow and cardiovascular responses with fresh blood viscosity during hypervolemic hemodilution therapy for focal cerebral ischemia , abstracted. Neurology 1981;; 32:132.
51 +
Chien S, Usami S, Taylor HM, et al:  Effects of hematocrit and plasma proteins on human blood rheology at low shear rates . J Appl Physiol 1966;;21:81-87.
52 +
Wells RE, Merrill EW:  Influence of flow properties of blood upon viscosity-hematocrit relationships . J Clin Invest 1962;;41:1591-1598.
53 +
Ott EO, Ladurner G, Lechner H:  Relationship between disturbed rheological properties and cerebral hemodynamics in recent cerebral infarction . Prog Biochem Pharmacol 1977;; 13:349-352.
54 +
Fan F-C, Chen RYZ, Schuessler GB, et al:  Effects of hematocrit variations on regional hemodynamics and oxygen transport in the dog . Am J Physiol 1980;;238:H545-H552.
55 +
Kusunoki M, Kimura K, Nakamura M, et al:  Effects of hematocrit variations on cerebral blood flow and oxygen transport in ischemic cerebrovascular disease . J CBF Metabol 1981;; 1:413-417.
56 +
Wood JH, Simeone FA, Snyder LL:  Cortical oxygen transport during hypervolemic hemodilutional therapy for focal cerebral ischemia , abstracted. Neurosurgery 1982;;10:781.
57 +
Fawer R, Justafre JC, Berger JP, et al:  Intravenous glycerol in cerebral infarctions: A controlled four-month trial . Stroke 1978;;9:484-486.
58 +
Gillilan LA:  Potential collateral circulation of the human cerebral cortex . Neurology 1974;;24:941-948.
59 +
Duvernoy HM, Delon S, Vannson JL:  Cortical blood vessels of the human brain . Brain Res Bull 1981;;7:519-579.
60 +
Masden JC, Azar-Kia B, Rubino FA:  Evaluation of recent cerebral infarction by computerized tomography . Arch Neurol 1977;;34:417-421.
61 +
Rengachary SS, Batnitsky S, Morantz RA, et al:  Hemicraniectomy for acute massive cerebral infarction . Neurosurgery 1981;;8:321-328.
62 +
Adams JH, Graham DI:  Twelve cases of fatal cerebral infarction due to arterial occlusion in the absence of atheromatous stenosis or embolism . J Neurol Neurosurg Psychiatry 1957;; 30:479-488.
63 +
Ng LKY, Nimmannitya J:  Massive cerebral infarction with severe brain swelling: A clinicopathological study . Stroke 1979;;1:158-163.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
McMurtry JG, Pool JL, Nova HR:  The use of Rheomacrodex in the surgery of intracranial aneurysms . J Neurosurg 1967;;26:218-222.
2 +
Kosnik EJ, Hunt WE:  Postoperative hypertension in the management of patients with intracranial aneurysms . J Neurosurg 1976;; 45:148-154.
3 +
Giannotta SL, McGillicuddy JE, Kindt GW:  Diagnosis and treatment of postoperative cerebral vasospasm . Surg Neurol 1977;;8:286-290.
4 +
Printz MB, Giannotta SL, Kindt GW, et al:  Treatment of patients with neurological deficits associated with cerebral vasospasm by intravascular volume expansion . Neurosurgery 1978;; 3:364-368.
5 +
Giannotta SL, Kindt GW:  Total morbidity and mortality rates in patients with surgically treated intracranial aneurysms . Neurosurgery 1979;;4:125-128.
6 +
Maroon JC, Nelson PB:  Hypovolemia in patients with subarachnoid hemorrhage: Therapeutic implications . Neurosurgery 1979;;4:223-225.
7 +
Sundt TM Jr:  Editorial comments of reference 6 . Neurosurgery 1979;;4:225.
8 +
Fleischer AD, Tindall GT:  Cerebral vasospasm following aneurysm rupture: A protocol for therapy and prophylaxis . J Neurosurg 1980;; 52:149-152.
9 +
Kudo T, Suzuki S, Iwabuchi T:  Importance of monitoring the circulating blood volume in patients with cerebral vasospasm after subarachnoid hemorrhage . Neurosurgery 1981;; 9:514-520.
10 +
Giannotta SL, McGillicuddy JE, Kindt GW:  Gradual carotid artery occlusion in the treatment of inaccessible internal carotid artery aneurysms . Neurosurgery 1979;;5:417-420.
11 +
Pritz MB:  Cardiopulmonary monitoring during graded cervical internal carotid artery occlusion. Physiological results and therapeutic implications . Neurosurgery 1980;;8:520-524.
12 +
Farhat SM, Schneider RC:  Observations on the effect of systemic blood pressure on intracranial circulation in patients with cerebrovascular insufficiency . J Neurosurg 1967;;27:441-445.
13 +
De Aranjo LC, Zappula RA, Yang WC, et al:  Angiographic changes to induced hypertension in cerebral vasospasm: Case report . J Neurosurg 1978;;49:312-315.
14 +
Montgomery EB, Grubb RL, Raichle ME:  Cerebral hemodynamics and metabolism in postoperative cerebral vasospasm and treatment with hypertensive therapy . Ann Neurol 1981;; 9:502-506.
15 +
Gilroy J, Barnhart MI, Meyer JS:  Treatment of acute stroke with dextran 40 . JAMA 1969;;210:293-298.
16 +
Heiss W-D, Prosenz P, Tschabitscher H, et al:  Effect of low-molecular dextran on total cerebral blood flow and on regional flow within ischemic brain lesions . Eur Neurol 1972;;8:129-133.
17 +
Gottstein U, Sedlmeyer I, Heuss A:  Treatment of acute cerebral ischemia with low-molecular dextran: Results of a retrospective study . Dtsch Med Wochenschr 1976;;101:223-227.
18 +
Kaste M, Fogelholm R, Waltimo O:  Combined dexamethasone and low-molecular-weight dextran in acute brain infarction: Double-blind study . Br Med J 1976;;2:1409-1410.
19 +
Matthews WB, Oxburg JM, Grainger KMR, et al:  A blind controlled trial of dextran-40 in the treatment of ischaemic stroke . Brain 1976;;99:193-206.
20 +
Eisenberg S:  Blood viscosity and fibrinogen concentration following cerebral infarction . Circulation 1966;;33-34( (suppl 2) ):10-14.
21 +
Ott EO, Lechner H, Aranibar A:  High blood viscosity syndrome in cerebral infarction . Stroke 1974;;5:330-333.
22 +
Harrison MJG, Pollack S, Kendall BE, et al:  Effect of haematocrit on carotid stenosis and cerebral infarction . Lancet 1981;;2:114-115.
23 +
Thomas DJ, duBoulay GM, Marshall J, et al:  Effect of haematocrit on cerebral blood flow in man . Lancet 1977;;2:941-943.
24 +
DeWeese JA, May AG, Lipchik EO, et al:  Anatomic and hemodynamics correlations in carotid artery stenosis . Stroke 1970;;1:149-157.
25 +
DeLong RN: The Neurologic Examination , ed 4. Hagerstown, Md, Harper & Row Publishers Inc, 1979;, p 338.
26 +
Hint H:  The pharmacology of dextran and the physiological background for the clinical use of Rheomacrodex and Macrodex . Acta Anaesthesiol Belg 1968;;19:119-138.
27 +
Czer LSB, Shoemaker WC:  Optimal hematocrit value in critically ill postoperative patients . Surg Gynecol Obstet 1978;;147:363-368.
28 +
Huntsberger DV, Leaverton PE: Statistical Inference in the Biomedical Sciences . Boston, Allyn & Bacon Inc, 1970;, pp 133, 135-136.
29 +
Jones TH, Morawetz RB, Crowell RM, et al:  Thresholds of focal cerebral ischemia in awake monkeys . J Neurosurg 1981;;54:773-782.
30 +
Crowell RM, Marcoux FW, DeGirolami U:  Variability and reversibility of focal cerebral ischemia in unanesthetized monkeys . Neurology 1981;;31:1295-1302.
31 +
Takagi S, Shinohara Y:  Internal carotid occlusion: Volume of cerebral infarction, clinical findings and prognosis . Stroke 1981;;12:835-839.
32 +
Kogure K, Busto R, Scheinberg P:  The role of hydrostatic pressure in ischemic brain edema . Ann Neurol 1981;;9:273-282.
33 +
Cook P, James I:  Cerebral vasodilators, part 1 . N Engl J Med 1981;;305:1508-1513.
34 +
Cook P, James I:  Cerebral vasodilators, part 2 . N Engl J Med 1981;;305:1560-1564.
35 +
Wood JH, Simeone FA, Snyder LL, et al:  Hemodilutional and nonhemodilutional hypervolemia in treatment of focal cerebral ischemia . J CBF Metabol 1981;;1( (suppl 1) ):S178-S179.
36 +
Wood JH, Snyder LL, Simeone FA, et al:  Cerebrovascular and cardiac responses to intravascular volume expansion following focal cerebral ischemia , abstracted. Stroke 1981;;12:130.
37 +
Wood JH, Simeone FA, Snyder LL, et al:  Treatment of experimental focal ischemia with intravascular volume expansion . Neurology 1981;; 32(a):153.
38 +
Wood JH, Simeone FA, Fink EA, et al:  Hypervolemic hemodilution in experimental focal cerebral ischemia: Elevation of cardiac output, regional cortical blood flow and intracranial pressure following low-molecular-weight dextran infusions . J Neurosurg , in press.
39 +
Gottstein U:  Cerebral blood flow, CMRO2 and CMR of glucose in patients with hypo and hyperchromatic anemia and polycythemia: The effect of hemodilution on CBF, CMR and hematocrit , in Meyer JS, Lechner H, Reivich M (eds): Cerebral Vascular Disease . New York, Elsevier North Holland Inc, 1979;, vol 2, pp 225-229.
40 +
Henriksen L, Paulson OB, Smith RM:  Cerebral blood flow following normovolemic hemodilution in patients with high hematocrit . Ann Neurol 1981;;9:454-457.
41 +
Pollock S, Tsitsopoulos P, Harrison MJG:  The effect of hematocrit on cerebral perfusion and clinical status following carotid occlusion in the gerbil . Stroke 1982;;13:167-170.
42 +
Wood JH, Simeone FA, Kron RE, et al:  Rheologic aspects of experimental hypervolemic hemodilution with low-molecular-weight dextran: Relationships of corticol blood flow, cardiac output and intracranial pressure to fresh blood viscosity and plasma volume . Neurosurgery , in press.
43 +
Kinkel WR, Jacobs L:  Computerized axial transverse tomography in cerebrovascular disease . Neurology 1976;;26:924-930.
44 +
Wing SD, Norman D, Pollock JA, et al:  Contrast enhancement of cerebral infarcts in computed tomography . Radiology 1976;;121:89-92.
45 +
Norton GA, Kishore PRS, Lin J:  CT contrast enhancement in cerebral infarction . AJR 1978;;131:881-885.
46 +
Masden JC, Azar-Kia B, Rubino FA:  Evaluation of recent cerebral infarction by computerized tomography . Arch Neurol 1977;;34:417-421.
47 +
Alcala H, Gado M, Torack RM:  The effect of size, histologic elements, and water content on the visualization of cerebral infarcts: A computerized cranial tomographic study . Arch Neurol 1978;;35:1-7.
48 +
Wood JH, Snyder LL, Simeone FA:  Failure of intravascular volume expansion without hemodilution to elevate cortical blood flow in region of experimental focal ischemia . J Neurosurg 1982;;56:80-91.
49 +
Wood JH, Simeone FA, Kron RE, et al:  Relationship of cortical blood flow and cardiovascular responses to alteration in fresh blood viscosity as determined by capillary stepresponse viscometry . J CBF Metabol 1981;; 1( (suppl 1) ):S233-S234.
50 +
Wood JH, Simeone FA, Kron RE, et al:  Correlation of cortical blood flow and cardiovascular responses with fresh blood viscosity during hypervolemic hemodilution therapy for focal cerebral ischemia , abstracted. Neurology 1981;; 32:132.
51 +
Chien S, Usami S, Taylor HM, et al:  Effects of hematocrit and plasma proteins on human blood rheology at low shear rates . J Appl Physiol 1966;;21:81-87.
52 +
Wells RE, Merrill EW:  Influence of flow properties of blood upon viscosity-hematocrit relationships . J Clin Invest 1962;;41:1591-1598.
53 +
Ott EO, Ladurner G, Lechner H:  Relationship between disturbed rheological properties and cerebral hemodynamics in recent cerebral infarction . Prog Biochem Pharmacol 1977;; 13:349-352.
54 +
Fan F-C, Chen RYZ, Schuessler GB, et al:  Effects of hematocrit variations on regional hemodynamics and oxygen transport in the dog . Am J Physiol 1980;;238:H545-H552.
55 +
Kusunoki M, Kimura K, Nakamura M, et al:  Effects of hematocrit variations on cerebral blood flow and oxygen transport in ischemic cerebrovascular disease . J CBF Metabol 1981;; 1:413-417.
56 +
Wood JH, Simeone FA, Snyder LL:  Cortical oxygen transport during hypervolemic hemodilutional therapy for focal cerebral ischemia , abstracted. Neurosurgery 1982;;10:781.
57 +
Fawer R, Justafre JC, Berger JP, et al:  Intravenous glycerol in cerebral infarctions: A controlled four-month trial . Stroke 1978;;9:484-486.
58 +
Gillilan LA:  Potential collateral circulation of the human cerebral cortex . Neurology 1974;;24:941-948.
59 +
Duvernoy HM, Delon S, Vannson JL:  Cortical blood vessels of the human brain . Brain Res Bull 1981;;7:519-579.
60 +
Masden JC, Azar-Kia B, Rubino FA:  Evaluation of recent cerebral infarction by computerized tomography . Arch Neurol 1977;;34:417-421.
61 +
Rengachary SS, Batnitsky S, Morantz RA, et al:  Hemicraniectomy for acute massive cerebral infarction . Neurosurgery 1981;;8:321-328.
62 +
Adams JH, Graham DI:  Twelve cases of fatal cerebral infarction due to arterial occlusion in the absence of atheromatous stenosis or embolism . J Neurol Neurosurg Psychiatry 1957;; 30:479-488.
63 +
Ng LKY, Nimmannitya J:  Massive cerebral infarction with severe brain swelling: A clinicopathological study . Stroke 1979;;1:158-163.

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