Dr Matthew A Butkus

• The CRISMA (Clinical Research, Investigation, and
• Systems Modeling of Acute Illness) Laboratory,
• Department of Critical Care Medicine,
• University of Pittsburgh,
• Pittsburgh, PA, USA

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Most sufferers who survive for greater than 24 hours demonstrate bilateral symmetric hypodense lesions within the putamina, globi pallidi, and generally the deep cerebral white matter (30-15). Enhancement is variable, ranging from none to peripheral enhancement of the putaminal lesions. Ethylene Glycol Poisoning Recent stories from the American Association of Poison Control Centers indicate that ethylene glycol is the third most common chemical liable for deaths by nonpharmaceutical poisoning (following ethanol and carbon monoxide). Note focal acute hemorrhage in the best basal ganglia and posterior limb of the interior capsule. Ethylene glycol is a colorless, odorless, sweet-tasting, however poisonous type of alcohol that may be a widespread component found in lots of family products such as antifreeze, deicing options, and windshield wiper fluids. When ingested, ethylene glycol causes metabolic acidosis and may damage the mind, liver, kidneys, and lungs. The toxicity of ethylene glycol is mediated by its metabolites, mainly glycolic acid and oxalate. Glycolate is then metabolized to oxalate, which precipitates with calcium as calcium oxalate and is deposited in varied tissues. The high anion hole of metabolic acidosis and osmolar gap resolve within 24 to seventy two hours. Emergent hemodialysis is suitable if the ethylene glycol degree is greater than 50 mg/dL and may be life saving. Imaging findings of acute ethylene glycol toxicity embrace edema within the basal ganglia, thalami, midbrain, and higher pons (30-19). Hemorrhagic putaminal necrosis, much like that observed in methanol intoxication, may be seen in subacute and chronic circumstances. Amphetamines and Derivatives the "hedonic" and addictive properties of drugs of abuse-particularly amphetamines and cocaine-are a minimum of partly associated to elevated dopamine ranges in the synapses of monoaminergic neurons although multiple other neurotransmitter systems. Most addictive medicine are excitotoxic and cause two major types of pathologies: vascular occasions. Functional neuroimaging studies have additionally demonstrated that drugs of abuse are associated with dysfunctions in a variety of overlapping mind regions. Working reminiscence, inhibitory management, attention, and decision-making are all negatively impacted, the degree of which correlates with the severity and chronicity of abuse. Acute hippocampal necrosis with subsequent atrophy has been reported in continual ecstasy users. Benzodiazepines Benzodiazepines, generally known as "benzo," are psychoactive drugs used to treat anxiety, insomnia, seizures, muscle spasms, and alcohol withdrawal. Benzodiazepines such as (30-21) A 32y feminine methamphetamine abuser had sudden extreme headache and coma. Benzodiazepine overdose has been associated with hypoxicischemic encephalopathy (30-24), hemorrhagic ischemic strokes (30-25), and delayed toxic leukoencephalopathy. Rupture of a preexisting aneurysm or underlying vascular malformation accounts for nearly half of all cocaine-related hemorrhagic strokes (30-28). Cocaine also facilitates platelet aggregation and may result in thrombotic vascular occlusion. Acute cerebral vasoconstriction and/or cocaine-induced vasculopathy could lead to ischemic strokes. Snorted cocaine causes extreme vasoconstriction within the vascular plexus of the nasal septal mucosa (Kiesselbach plexus). Etiology Regardless of the route of administration, the antagonistic influence of cocaine on the brain is largely associated to its vascular effects. Pathology Macroscopic hemorrhages, particularly in the putamen and exterior capsule, are the commonest gross pathologic findings and are twice as common as ischemic strokes. Microscopically, cocaine arteriopathy is characterized by inflammatory modifications and necrosis. Nearly one-third of strokes in sufferers youthful than forty five years old are drug related, with 80-90% occurring in the fourth and fifth many years. The onset of cocaine-related stroke could additionally be immediate if hypertensive or subarachnoid hemorrhage occurs. Cocaine-induced vasculopathy with ischemic infarcts may happen as a lot as per week after use.

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Enhancement varies from none (early) to intense gyriform enhancement a number of days later (12-52D). Primary neoplasms corresponding to diffusely infiltrating astrocytoma often contain white matter or white matter plus cortex. Acute cerebral ischemia-infarction occurs in a typical vascular distribution, involving each the cortex and white matter. Postictal edema is transient however usually extra widespread, usually involving most or all the hemispheric cortex. Temporal lobe confluent hyperintensities with patchy foci of marked hypointensity are according to encephalomalacia and persistent hemorrhage. Similar findings were present in the insular cortex and cingulate gyri (not shown). The median interval between transplantation and onset of neurologic signs is three weeks. Patients typically current with altered psychological status, shortterm reminiscence loss, and seizures. Note edema and mass impact, seen as hyperintensity in both cerebellar hemispheres. Postictal hippocampal hyperemia is transient, and extrahippocampal involvement is absent. The most typical nonepidemic viral encephalitis, herpes encephalitis, was discussed earlier. Miscellaneous Acute Viral Encephalitides Viral encephalitis is a medical emergency. Timely, accurate diagnosis and immediate remedy can improve survival and reduce the likelihood of mind harm. Ischemic or hemorrhagic strokes, aneurysms, subarachnoid and parenchymal hemorrhages, arterial ectasias, and dissections have all been described. Meningitis is essentially the most frequent general manifestation (50% of cases) and the commonest medical presentation in immunocompetent sufferers (90%). Transmission increases in warmer months; within the Northern hemispheres, peak activity is from July via October. Hemorrhage and enhancement are typically absent, helping differentiate rabies from Japanese encephalitis and different viral encephalitides. Onset of neurologic deterioration happens a quantity of days to a week after the primary indicators of influenza an infection. The morbidity and mortality are particularly impressive among patients with trisomy 21 (12-68). Nearly 55,000 deaths because of rabies encephalitis happen annually, 99% of them in Asia and Africa. The virus is ample within the saliva of the infected animal and is deposited in chew wounds. The history and medical presentation are highly suggestive, but the definitive analysis requires laboratory confirmation of rabies antigen or rabies antibodies or isolation of the virus from biologic samples. Periventricular white matter, cerebellar, and spinal wire involvement has been reported in some circumstances. The midbrain, pons, cerebellum, and deep cerebral white matter are frequently involved. Miscellaneous Infectious Viral Encephalitides A host of other viral encephalitides have been identified. Arthropod-borne (ticks and mosquitoes) viruses represent an underappreciated explanation for encephalitis in older pediatric sufferers and adults. In this section, we briefly contemplate two persistent encephalitides: the measles reactivation syndrome known as subacute sclerosing panencephalitis and Rasmussen encephalitis. Measles virus disproportionately affects youngsters in areas with low measles vaccination rates. Symptom onset is often insidious, with behavioral and cognitive deterioration, myoclonic seizures, and progressive motor impairment. More than 95% of sufferers die within 5 years, most inside 1-6 months after symptom onset.

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Multiple osteochondromas ("osteochondromatosis") have the next propensity to bear malignant transformation. Chondroma/enchondromas of the cranium base are sessile, easily lobulated, expansile plenty that comprise curvilinear matrix calcifications and sometimes mature bone (22-30). Osteochondromas are sessile or pedunculated bony lots that are contiguous with and project from their underlying bone of origin. Osteochondromas might exhibit a "cap" of matrix with speckled calcification that enhances mildly following contrast administration. Note matrix mineralization, calcified arcs, and dysplastic cortical bone inside the mass. Neoplasms, Cysts, and Tumor-Like Lesions 676 Osteomas are seen as dense masses of well-demarcated mature lamellar bone. When they contain the calvaria, radiating spicules of lamellar bone are interspersed with vascular channels of various sizes (22-33). Hemangiomas are classified on the basis of their dominant vessels and could be capillary, cavernous, or blended lesions. Most intracranial hemangiomas are cavernous and comprise large, endothelium-lined spaces separated by fibrous septa. True intracranial capillary hemangiomas are very rare and consist of smaller vessels with out fibrous septa. Hemangioma Terminology Hemangiomas are benign nonmeningothelial mesenchymal tumors. They are frequent vascular neoplasms that closely resemble normal vessels and are found in all organs of the physique (22-32). Etiology Hemangiomas probably arise by endothelial hyperplasia and hamartomatous-like proliferation. Intracranial hemangiomas could be situated in several cranial compartments however are almost all the time extraaxial. Most are discovered within the backbone; the diploic area of the calvaria is the most common intracranial site. Hemangiomas can happen at any age although the peak presentation is between the fourth and fifth many years. Scalp hemangiomas presenting with Kasabach-Merritt syndrome (consumptive coagulopathy as a result of sequestration and destruction of clotting factors inside the lesion) have been reported. Cavernous sinus hemangiomas can be asymptomatic however often present with headache, diplopia, or other cranial neuropathies similar to anisocoria. Capillary hemangiomas of infancy (usually within the pores and skin, scalp, orbit, or oral mucosa and only hardly ever involving the brain) seem inside a number of months of birth, grow rapidly, plateau, after which involute. Calvarial hemangiomas are sometimes left alone unless tumor growth is demonstrated. Radiation (gamma knife surgery) has been used with some success in a quantity of reported circumstances and may turn into the primary treatment selection for hemangiomas in critical locations such as the cavernous sinus. The hypointense "dots" of radiating bone spicules give the lesion a striped appearance. Scattered hyperintensities usually are brought on by fat-not hemorrhage-within the lesion. Dural and venous sinus hemangiomas can carefully resemble meningiomas, with sluggish, persistent contrast accumulation within the capillary and venous phases of the angiogram. Differential Diagnosis the differential diagnosis of calvarial hemangioma includes "holes in the skull" attributable to venous lakes and arachnoid granulations, burr holes, dermoids, eosinophilic granuloma, and metastasis. These cells are capable of giving rise to the spectrum of histologic varieties seen in nonmeningothelial neoplasms. The Epstein-Barr virus might play a role in growing clean muscle tumors, which sometimes happen in immunocompromised sufferers. Some (such as rhabdomyosarcoma and Ewing sarcoma) are rather more frequent in kids than adults. Chondrosarcomas are tumors of younger adults with a imply age of 37 years at presentation.

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The necessary intratemporal branches of the facial nerve from high to backside are the greater superficial petrosal nerve (parasympathetic fibers that supply the lacrimal gland), the stapedius nerve (innervation of the stapedius muscle), and the chorda tympani (taste from the anterior two-thirds of the tongue) (23-26). The facial nerve exits the skull at the stylomastoid foramen, then enters the parotid gland. Once contained in the gland, the extracranial facial nerve ramifies into its terminal motor branches, which innervate the muscle tissue of facial features (23-25). With the exception of the labyrinthine phase, a robust vascular plexus surrounds a lot of the intratemporal facial nerve. Therefore, the facial nerve is the one cranial nerve with segments that will exhibit some enhancement following distinction administration. The geniculate ganglion enhances in 75% of cases, and tympanic segment enhancement happens in half of all instances. Segmental facial nerve enhancement is extra conspicuous at higher area strengths (3. It is essential to know whether a facial nerve deficit is central ("upper motor neuron") or peripheral ("decrease motor neuron"). Upper (central or supranuclear) motor neuron harm, because of a parenchymal lesion above the brainstem, ends in paralysis of the contralateral muscle tissue of facial features however spares the brow. Lower motor neuron facial palsy entails paralysis of all ipsilateral muscles of facial expression. In such cases, imaging ought to lengthen from the brainstem via the parotid gland. If a decrease motor neuron facial damage is current, further data concerning the so-called particular functions of the facial nerve is crucial. It offers parasympathetic innervation to the lacrimal, submandibular, and sublingual glands. The intraaxial section consists of the facial nerve nuclei that lie within the ventrolateral pons. Efferent fibers from the motor nucleus loop dorsally around the abducens nucleus, then move anterolaterally to exit the brainstem at the pontomedullary junction (23-21). If these special features are spared, the trigger of a lower motor neuron facial palsy is extracranial. If the special features are affected, figuring out precisely which of them are concerned helps localize lesion extent. Malignant parotid tumors-especially adenoid cystic carcinoma-have a marked propensity to enter the stylomastoid foramen and invade up the intratemporal facial nerve. The most distal of the intratemporal facial nerve branches is the chorda tympani, which is affected first. As tumor progresses more cephalad, the next affected department is the stapedius nerve. As tumor reaches the geniculate ganglion, the larger superficial petrosal nerve is compromised, resulting in issues with lacrimation. A lesion proximal to the geniculate ganglion will trigger facial paralysis and affect all three special functions. Cochlear nerve/modiolus, inferior /superior vestibular nerves, nuclei in medulla, tracts in inferior cerebellar peduncle. Ask if upper or decrease motor neuron Parotid malignancies "creep up" facial nerve Special capabilities affected (taste, hyperacusis, lacrimation) It is the afferent sensory nerve liable for listening to and the sense of stability. The cochlear nerve arises from the spiral ganglion within the modiolus of the cochlea. Its fibers coalesce to type the superior and inferior vestibular nerves, that are separated by a bony bar called the falciform (transverse) crest. The cochlear nuclei are found in the restiform physique at the lateral surface of the inferior cerebellar peduncle. At least 90-95% of all lesions that cause unilateral sensorineural listening to loss-and are detected on imaging-are vestibulocochlear schwannomas. It is a particular sensory nerve (responsible for taste in the posterior third of the tongue) as well as a daily sensory nerve (innervating center ear, pharynx). It carries parasympathetic fibers to the parotid gland and is the motor provide to the stylopharyngeus muscle. All are in the higher and center medulla, anterolateral to the inferior fourth ventricle. The tracts course anterolaterally from the nuclei to exit or enter the medulla in the postolivary sulcus.

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Progressive, quickly spreading, in ammatory in ection located within the deep ascia, with secondary necrosis o the subcutaneous tissues. S pyogenes (group A hemolytic streptococci) and S aureus are the most typical inciting bacteria b. Clinical examination reveals rapidly spreading, erythematous skin modifications with pores and skin discoloration and subcutaneous emphysema. Carotid paraganglia-located in the adventitia o the posteromedial facet o the bi urcation o the common carotid artery b. Chie cells (amine precursor and uptake decarboxylase cells) and sustentacular cells (modi ed Schwann cells) organized in clusters often identified as Zellballen ypes a. Arteriography reveals characteristic splaying o the interior and exterior carotid arteries (Lyre sign) 6. May current with pulsatile tinnitus, aural ullness, listening to loss, and cranial neuropathies. Examination may present vascular center ear mass, which displays Brown sign (blanching o mass with optimistic pneumatoscopic pressure). O en current with a painless neck mass with tongue weak spot, hoarseness, dysphagia, and a Horner syndrome 5. Radiography reveals vascular lesion that displaces the interior carotid artery anteromedially iii. Ninety p.c o primaries finally ound with repeated examination, biopsies, and scanning iv. Paramedian orehead-supratrochlear artery Cha pter 54: Highlights and Pearls 1099 c. Pectoralis major-thoracoacromial artery and internal mammary artery per orators c. Platysma-occipital, postauricular, acial, superior thyroid, and transverse cervical d. Hyper ractionated radiation techniques allow a better cumulative dose per remedy. N2a-single ipsilateral lymph node higher than 3 cm, lower than and equal to 6 cm iii. N2c-bilateral or contralateral lymph nodes, none greater than and equal to 6 cm v. Postlaryngectomy sufferers have a high probability o recurrence when a Delphian node is involved. Retinoids seem to scale back the likelihood o creating second primaries in sufferers with head and neck squamous carcinomas. Spheroidal, cyst-like compartment with ollicular epithelium, colloid heart, paraollicular cells, capillaries, connective tissue, and lymphatics ii. Principal element o colloid is giant iodinated glycoprotein referred to as thyroglobulin B. Used as a marker in medullary thyroid cancer Cha pter 54: Highlights and Pearls 1101 D. Not used as a screening take a look at (estimated value o detecting one case o medullary cancer with calcitonin is $12,500) v. Ninety- ve p.c are both adenomas, colloid nodules, cysts, thyroiditis, or carcinoma. Most accurate device or selecting sufferers requiring surgery, has elevated the proportion o malignant nodules excised by 60% to one hundred pc and decreased percentage o benign nodules excised by 34% to 70%. Reveals further nodules in 20% to 48% o patients re erred or solitary nodule d. Macro ollicular � May be watched � wenty p.c or much less o patients may have a decrease in nodule dimension with four therapy 2. Micro ollicular � Surgical excision to evaluate or capsular or vascular invasion � oxic adenomas (a) Beta blockers (b) T ionamide therapy (methimazole and propylthiouracil) Inhibits thyroperoxidase, blocks three and four synthesis Propylthiouracil blocks the peripheral conversion o four to three, causes liver ailure, and is not rst line three. I131 ameliorates hyperthyroidism and reduces total thyroid quantity by 45% in 2 years 4. Lymphocytic in ltration, germinal center ormation, H�rthle cells, and ollicular atrophy b. Woody goiter xed to surrounding buildings and progressive aerodigestive symptoms iv.

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Bilateral ractures occur 50% o the time (ie, parasymphysial and contralateral subcondylar) iv. Compressive orces occur alongside the in erior rim and areas o pressure develop alongside the superior rim a. When a racture happens, orces tend to distract superiorly and compress in eriorly 1. Un avorable ractures-displaced and distracted by pterygoid and masseter muscle tissue Cha pter fifty four: Highlights and Pearls 1131 2. Mandibular osteomyelitis a er racture is related to a racture via a tooth root. Classically used or uncomplicated subcondylar ractures and ractures with gross comminution or so tissue loss three. Placement o plates to overcome distracting orces and take advantage o compressive orces 3. Properly positioned miniplates can take benefit o dynamic compressive orces � Champy de ned areas or xation o miniplates along the best osteosynthesis traces G. There has been a development away rom obligatory exploration o all penetrating neck wounds; Immediate surgery at all times prudent or immediately li e-threatening accidents a. Angiography and esophagram are o en used to acquire urther in ormation in nonimmediately emergent cases iii. For Zone 2, Surgical exploration (angiography is usually not needed) is requently the rst-line remedy particularly with any o the ollowing signs: a. Contrast studies o the aortic arch are necessary ollowing cardiomediastinal injuries that outcome within the ollowing: i. Associated with head and neck trauma or venous per oration during routine head and neck procedures ii. Place patient in rendelenburg (head down) and le lateral decubitus place (this traps air in the ventricle and prevents ejection into pulmonary system) iv. Cardiac puncture may be required or aspiration o air (also possible with a SwanGanz catheter) Connective Tissue Disorders A. Idiopathic in ammatory myopathies characterized by symmetric proximal muscle weak point ii. Heliotrope rash: reddish-violaceous eruption on the higher eyelids with accompanying eyelid swelling iii. Ninety % o sufferers develop auricular chondritis and nonerosive in ammatory polyarthritis iii. Heterogeneous group o disorders characterised by thickened, sclerotic/ brotic lesions ii. A ects decrease two-thirds (smooth muscle) o esophagus and is often the preliminary criticism b. Extraglandular signs could additionally be seen in addition to major exocrine gland pathology (ie, bronchiectasis) vi. Associated with connective tissue issues (rheumatoid arthritis, lupus erythematosus) b. Myoepithelial cells are current in biopsy specimens o Sj�gren syndrome but not in lymphoma (may be carried out o lip, sputum, palate) 1134 Pa rt 9: Review x. Must be distinguished rom sicca-like syndromes, which have xerostomia and/or xerophthalmia, adverse exams, and normal biopsy a. Angiocentric, epithelial-type necrotizing granulomas with the presence o large cells and histiocytes v. Apnea a er tracheotomy as a outcome of respiration is driven by hypoxia in these sufferers. Postobstructive pulmonary edema a er tracheostomy or tonsillectomy due to the sudden elimination o excessive intraluminal pressures. Cocaine (many lawsuits settled solely as a outcome of affiliation o cocaine use and poor cardiac consequence throughout case) a. Causes cavitary lesions a er immune unction returns which may cause li e-threatening hemoptysis or hemorrhage Coccidiomycosis i. Involvement o skin, mucous membranes, thyroid, eyes, trachea, salivary glands, extreme erosions o epiglottis iv. The physique produces 20 mg o cortisol per day, which is equal to 5 mg o prednisone, four mg o methylprednisolone, or 0. Unrelated group o lesions sharing the identical histologic eatures as their frequent denominator (benign cellular brous tissue containing variable amounts o mineralized material) ii.

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Gain: ampli cation or the acoustic energy added to input sound, the di erence between the input and output. Components All listening to instruments have a microphone, ampli er, and output receiver powered by a battery. For individuals with tinnitus and listening to loss, a hearing help itself may assist masks the tinnitus. In actual ear measurements, a probe tube microphone measures sound very close to the tympanic membrane, thereby together with the (real ear) e ects of the outer ear and canal and the lack of the pure acquire produced by the ear canal resonance near 2700 Hz, when a listening to assist is put in place. Real-ear instruments embody tting formulation or "prescriptions" of gain and s output for max audibility of speech without being uncomfortable. From three to 21 years of age, federal and state mandates require that children have a "free, appropriate training" in the "least restrictive surroundings. School-age youngsters could be taught speci c speech (articulation, voice) and language (vocabulary, grammar) expertise. Adults who turn out to be hard of listening to could bene t from auditory training and speech studying lessons. Adventitiously deafened adults can be helped to reduce the usual deterioration in speech and voice (due to absent auditory self-monitoring) and to turn into better users of visible cues. Counseling and vocational steering may be invaluable to individuals with listening to impairment. Noise-Induced Hearing Loss and Industrial Audiology Exposure to excessively sturdy sounds might destroy auditory cells, resulting in hearing loss. Such losses are o en described as "noise-induced," but any sound-noise, speech, music-of su cient intensity can damage listening to. Typically, the hearing loss begins in a notch pattern in the 3000- to 6000-Hz region but with repeated publicity broadens to the other frequency areas giving a shallower notch. A signal of early damage in shooters is an asymmetrical 4000-Hz notch loss, which is worse within the ear opposite the shoulder from which the gun is purple. By informing, counseling, and motivating individuals to protect their listening to, otolaryngologists can make an enormous impression on preventing listening to impairment. A listening to conservation program has four main parts: � Assess the level and cumulative dose of noise exposure in a given setting using a sound level meter and dosimeter. Earmu s, custom- tted earplugs, or disposable earplugs provide 20 to 40 dB of sound attenuation, extra in excessive frequencies than in low frequencies. Some passive gadgets, corresponding to valves, are amplitude sensitive to permit relatively regular hearing. For some occupations, notably musicians, the greater sound discount for top frequencies of listening to protectors is objectionable as a outcome of it alters sound high quality. However, to o set the blockage e ect of the ear protectors, some units include slight ampli cation so as to hear traditional dialog and environmental sounds. Another technique is "active noise discount," by which the sound part is inverted 180� to cancel the noise. Y 2007 Position Statement: Principles and Guidelines for Early ear Hearing Detection and Intervention Programs. The energetic, complex set of operations carried out by the central nervous system on auditory inputs is termed: A. These embrace the summating potential, motion potential, and the cochlear microphonic. It can be necessary to observe that the normative data is altered by the electrode website when analyzing the outcomes. This is an invasive approach that requires the tympanic membrane to be anesthetized prior to placement. This ar- eld placement produces low amplitudes that require signi cantly more sign averaging. The most popular utilization is as a screening instrument to rule out acoustic neuromas/vestibular schwannoma. The click on stimuli will give an estimated hearing sensitivity threshold or s the 1000- to 4000-Hz area. With the use o high-pass masking techniques, a click stimulus can be used to collect requency-speci c in ormation. The consensus at present is that the responses are chie y neurogenic in make-up, not myogenic as previously thought.

Sven, 48 years: The surrounding brain typically displays inflammatory modifications, with gliosis and edema leading to mass effect.

Rakus, 29 years: Enterobacter species like Citrobacter are a standard explanation for cerebral abscess in neonates.

Emet, 41 years: Skull fractures are current in practically half of all instances (294), and scalp hematomas could be readily detected.

Silas, 40 years: I degeneration o higher than 90% is identi ed on the a ected facet inside 2 weeks a er the damage, surgical decompression o the acial nerve on the a ected web site must be thought of.

Renwik, 45 years: T oracic spinal cord sympathetic trunk superior cervical ganglion external carotid artery salivary glands O.

Quadir, 49 years: T rombocytopenic purpura: purpura due to marked decrease in platelets rom a variety o causes.

Bufford, 36 years: However, the illness typically follows an atypical course, waxing and waning over a period of several months.

Runak, 23 years: In others, liquefaction of the hematoma over time produces serous blood-tinged fluid.

Gunock, 63 years: Intense homogeneous enhancement is seen following distinction administration (18-31).

Vibald, 34 years: The dura is repaired with temporalis ascia, ascia lata, lyophilized dura, or bovine pericardium gra s.

Urkrass, 24 years: Many-if not most-ectatic intracranial vessels are asymptomatic and discovered incidentally at post-mortem or on imaging studies (10-23).

Sinikar, 33 years: It can be a prolonged procedure; moreover, the gear is mostly not available.

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