Complicações neurológicas da cirurgia cardíaca: revisão sobre a patogenia e bases para tratamento

Werneck, Lineu Cesar; Loures, Danton R. Rocha

doi:10.1590/S0004-282X1973000400004

Resumos

São relatadas as complicações neurológicas assinaladas em 320 pacientes submetidos a cirurgias cardíacas, com uma incidência de 7,8%. As etiologias mais comuns encontradas foram a embolia aérea (4,0%) e isquemia cerebral após hipotensão sistêmica (2,4%). Os autores analisam a patogenia das complicações cerebrais e tentam correlacioná-las com o fluxo sangüíneo cerebral, com o metabolismo cerebral e com a dinâmica dos pequenos vasos cerebrais. Uma revisão a respeito dos métodos para tratamento da isquemia cerebral é apresentada.

The neurological complications following 320 heart surgery, with an incidence of 7,8% are reported. The most common etiology were air embolus (4,0%) and cerebral ischaemia following hypotension (2,4%). The authors analyse the pathogenesis of the cerebral complication and attempt to correlate it with the cerebral blood flow, brain metabolism and dynamics of the small cerebral vessels. A revision about the most common methods of treatment of cerebral ischaemia is made.

Complicações neurológicas da cirurgia cardíaca. Revisão sobre a patogenia e bases para tratamento

Neurological complications of heart surgery. A review about the pathogenesis and treatment bases

Lineu Cesar Werneck^I; Danton R. Rocha Loures^II

^ICentro Neurológico e Serviço de Cirurgia Cardiovascular do Hospital Santa Cruz, Curitiba, Paraná: Auxiliar de Ensino do Departamento de Medicina (Neurologia) da Universidade Federal do Paraná

^IICentro Neurológico e Serviço de Cirurgia Cardiovascular do Hospital Santa Cruz, Curitiba, Paraná: Auxiliar de Ensino do Departamento de Cirurgia (Cirurgia Cardiovascular) da Universidade Federal do Paraná

RESUMO

São relatadas as complicações neurológicas assinaladas em 320 pacientes submetidos a cirurgias cardíacas, com uma incidência de 7,8%. As etiologias mais comuns encontradas foram a embolia aérea (4,0%) e isquemia cerebral após hipotensão sistêmica (2,4%). Os autores analisam a patogenia das complicações cerebrais e tentam correlacioná-las com o fluxo sangüíneo cerebral, com o metabolismo cerebral e com a dinâmica dos pequenos vasos cerebrais. Uma revisão a respeito dos métodos para tratamento da isquemia cerebral é apresentada.

SUMMARY

The neurological complications following 320 heart surgery, with an incidence of 7,8% are reported. The most common etiology were air embolus (4,0%) and cerebral ischaemia following hypotension (2,4%). The authors analyse the pathogenesis of the cerebral complication and attempt to correlate it with the cerebral blood flow, brain metabolism and dynamics of the small cerebral vessels. A revision about the most common methods of treatment of cerebral ischaemia is made.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Centro Neurológico Hospital Santa Cruz Rua do Rosário 144 80000 Curitiba, PR Brasil.

1. ALLARDYCE, D. B.; YOSHIDA, S. H. & ASHMORE, P. G. The importance of microembolism in the pathogenesis of organ dysfunction caused by prolonged use of the pump oxygenator. J. Thoracic & Cardiovas. Surg. 52:706, 1966.
2. ARFEL, G.; WEISS, J. & DuBOUCHET, N. EEG findings during open heart surgery with extra-corporeal circulation. In Meyer, J. S. e Gastaut, H. Cerebral Anoxia and the Electroencephalogram, Charles C. Thomas, Springfield (Illinois), 1961.
3. BRAWLEY, B. W.; STRANDNESS Jr., E. & KELLY, W. A. The physiologic response to therapy in experimental cerebral ischemia. Arch. Neurol. (Chicago) 17:80, 1967.
4. BRENNAN, R. W.; PATTERSON, R. H. & KESSLER, J. Cerebral blood flow and metabolism during cardiopulmonary bypass: evidence of microembolic encephalopathy. Neurology (Minneapolis) 21:665, 1971.
5. BRIERLEY, J. B. Systemic hypotension: neurological and neuropathological aspects. In Modern Trends in Neurology. Vol. 5. Appleton-Century-Crofts, London, 1970, pág. 164.
6. BROOK, M. Patogenia dos acidentes vasculares cerebrais em função dos conhecimentos atuais sobre circulação regional do encéfalo. Resumo do V Congresso Brasileiro de Neurologia, São Paulo, Julho 1972.
7. CARTER, C. C.; EICHLING, J. O.; DAVIS, D. O. & PERPOGOSSIAN, M. M. Correlation of regional cerebral blood flow with regional oxygen uptake using O¹⁵ method. Neurology (Minneapolis) 22:755, 1972.
8. CLASEN, R. A.; PANDOLFI, S. & HASS, G. M. Interrupted hypothermia in experimental cerebral edema. Neurology (Minneapolis) 20:279, 1970.
9. FIESCHI, C.; AGNOLI, A.; BATTISTINI, N.; BOZZAO, L. & PRENCIPE, M. Derangement of regional cerebral blood flow and of its regulatory mechanisms in acute cerebrovascular lesions. Neurology (Minneapolis) 18:1166, 1968.
10. FIESCHI, C.; AGNOLI, A.; BATTISTINI, N. & BOZZAO, L. Regional cerebral blood flow in patients with brain infarcts. Arch. Neurol. (Chicago) 15:653, 1966.
11. FISCHER, E. G. & AMES, A. Studies on mechanisms of impairment of cerebral circulation following ischemia: effect of hemodilution and perfusion pressure. Stroke 3:538, 1972.
12. FIESCHER-WILLIAMS, M.; GOTTSCHALK, P. G. & BROWELL, J. N. Transient cortical blindness. Neurology (Minneapolis) 20:353, 1970.
13. GILMAN, S. Cerebral disorders after open-heart operations. New Engl. J. Med. 272:489, 1965.
14. GILROY, J.; BARNHART, M. I. & MEYER, J. S. Treatment of acute stroke with dextran 40. J.A.M.A. 210:293, 1969.
15. GINSBERG, M. D. & MYERS, R. E. The topography of impaired microvascular perfusion in the primate brain following total circulatory arrest. Neurology (Minneapolis) 22:998, 1972.
16. GOTTSTEIN, U. & PAULSON, O. B. The effect of intracarotid aminophyline infusion on the cerebral circulation. Stroke 3:560, 1972.
17. HARPER, A. M.; DESHMUK, V. D.; ROWAN, J. O. & JENNETT, B. The influence of sympathetic nervous activity on cerebral blood flow. Arch. Neurol. (Chicago) 27:1, 1972.
18. HARRISON, M. J. G. & RUSSELL, R. W. Effect of dexamethasone on experimental cerebral infarction in the gerbil. J. Neurol. Neurosurg. Psychiat. 35:520, 1972.
19. HASBROUCK, J. D. & RIGOR, B. M. The oxygen tension of cerebrospinal fluid during cardiopulmonary bypass. J. Thoracic & Cardiovac. Surg. 58:754, 1969.
20. HEKMATPANAH, J. Cerebral blood flow dynamics in hypotension and cardiac arrest. Neurology (Minneapolis) 23:174, 1973.
21. HOEDT-RASMUSSEN, K.; SKINHOJ, E.; PAULSON, O.; EWALD, J.; BJERRUM, J. K.; FAHRENKRUG, A. & LASSEN, N. A. Regional cerebral blood flow in acute apoplecy (the luxury perfusion syndrome of brain tissue). Arch. Neurol. (Chicago) 17:271, 1967.
22. JAFFE, M. E.; McHENRY, L. C. & GOLDBERG, H. I. Regional cerebral blood flow measurement with small probes. Neurology (Minneapolis) 20:225, 1970.
23. JAVID, H.; TUFO, H. M.; NAJAFI, H.; DYE, W. S.; HUNTER, J. A. & JULIAN O. C. Neurological abnormalities following open-heart surgery. J. Thoracic & Cardiovasc. Surg. 58:502, 1969.
24. KOGURE, K.; FUJISHIMA, M.; SCHEINBERG, P. & REINMUTH, O. M. Effects of changes in carbon dioxide pressure and arterial pressure on blood flow in ischemic regions of the brain in dogs. Circulation Research 24:557, 1969.
25. LASSEN, N. A. Cerebral blood flow and oxygen consumption in man. Physiological Reviews 19:183, 1959.
26. LASSEN, N. A. The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2:1113, 1966.
27. McHENRY Jr., L. C. Cerebral blood flow. New Engl. J. Med. 274:82, 1966.
28. McHENRY Jr., L. C. Cerebral vasodilator therapy in stroke. Stroke 3:686, 1972.
29. McHENRY, L. C.; GOLBERG, H. I.; JAFFE, M. E.; KENTON III, E. J.; WEST, J. W. & COOPER, E. S. Regional cerebral blood flow. Arch. Neurol. (Chicago) 27:403, 1972.
30. McHENRY, L. C.; JEFFE, M. E.; KAWAMURA, J. & GOLBERG, H. I. Effect of papaverine on regional blood flow in focal vascular disease of the brain. New Engl. J. Med. 282:1167, 1970.
31. MEYER, J. S.; CHARNEY, J. Z.; RIVERA, V. M. & MATHEW, N. T. Cerebral embolization: prospective clinical analysis of 42 cases. Stroke 2:541, 1971.
32. MEYER, J. S.; FUKUUCHI, Y.; SHIMAZU, K.; OHUCHI, T. & ERICSSON, A. D. Abnormal hemispheric blood flow and metabolism in cerebrovascular disease: therapeutic trials with 5% CO₂ inhalation, hyperventilation and intravenous infusion of THAM and mannitol Stroke 3:157, 1972.
33. MEYER, J. S.; FUKUUCHI, Y.; SHIMAZU, K.; OHUCHI, T. & ERICSSON, A. D. Effect of intravenous infusion of glycerol on hemispheric blood flow and metabolism in patients with acute cerebral infarction. Stroke 3:168, 1972.
34. MEYER, J. S.; GOTOH, F.; GILROY, J. & NARA, N. Improvement in brain oxygenation and clinical improvement in patients with strokes treated with papaverine hydrochloride. J.A.M.A. 194:957, 1965.
35. MEYER, J. S.; KANDA, T.; FUKUUCHI, Y.; SHIMAZU, K.; DENNIS, E. W. & ERICSSON, A. D. Clinical prognosis correlated with hemispheric blood flow in cerebral infarction. Stroke 2:383. 1971.
36. MEYER, J. S.; KANDA, T.; SHINOHARA, Y.; FUKUUCHI, Y.; SHIMAZU, K.; ERICSSON, A. D. & GORDON, W. H. Effect of hexabendine on cerebral hemispheric blood flow and metabolism. Neurology (Minneapolis) 21:691, 1971.
37. MEYER, J. S.; SAWADA, T.; KITAMURA, A. & TOYODA, M. Cerebral oxygen, glucose, lactate and pyruvate metabolism in stroke. Therapeutic considerations. Circulation 37:1036, 1968.
38. MEYER, J. S.; TERAURA, T.; MARX, P.; HASHI, K.; & SAKAMOTO, K. Brain swelling due to experimental cerebral infarction. Changes in vasomotor capacitance and effects of intravenous glycerol. Brain 95:833, 1972.
39. MILLER, J. R. & MYERS, R. E. Neurological effects of systemic circulatory arrest in the monkey. Neurology (Minneapolis) 20:715, 1970.
40. MILLER, J. R. & MYERS, R. E. Neuropathology of systemic circulatory arrest in adult monkeys. Neurology (Minneapolis) 22:888, 1972.
41. MILLIKAN, C. H. Reassessment of anticoagulant therapy in variou types of occlusive cerebrovascular disease. Stroke 2:201, 1971.
42. MILLIKAN, C. H. Summary of the eight Princeton Conference on cerebral vascular diseases (January 5-7, 1972, Nassau Tavern, Princeton, New Jersey). Stroke 3:105, 1972.
43. OLESEN, J. Total co₂, lactate and pyruvate in brain biopsies taken after freezing the tissue in situ. Acta Neurol. Scandinav. 46:141, 1970.
44. OLESEN, J. & PAULSON, O. B. The effect of intra-arterial papaverine on the regional cerebral blood flow in patients with stroke or intracranial tumor. Stroke 2:148, 1971.
45. OLESEN, J.; PAULSON, O. B. & LASSEN, N. A. Regional cerebral blood flow in man determined by the initial slope of the clearence of intra-arterially injected 133 Xe. Stroke 2:519, 1971.
46. PATTEN, B. M.; MENDELL, J.; BRUUN, B.; CURTIN, W. & CARTER, S. Double-blind study of the effects of dexamethasone on acute stroke. Neurology (Minneapolis) 22:377, 1972.
47. PATTERSON, R. H. & KESSLER, J. Microemboli during cardiopulmonary bypass detected by ultrasound. Surg. Gyn. .& Obst. 129:505, 1969.
48. PAULSON, G. W.; LOCKE, G. E. & YASHON, D. Cerebral spinal fluid lactic acid following circulatory arrest. Stroke 2:565, 1971.
49. PAULSON, O. B. Regional cerebral blood flow in apoplexy due to occlusion of the midle cerebral artery. Neurology (Minneapolis) 20:63, 1970.
50. PAULSON, O. B. Cerebral apoplexy (stroke): pathogenesis, pathophysiology and therapy as illustrated by regional blood flow measurements in the brain. Stroke 2:327, 1971.
51. POTCHEN, E. J.; DAVIS, D. O.; WHARTON, T.; HILL, R. & TAVERAS, J. M. Regional cerebral blood flow in man: a study of the xenon 133 washout method. Arch. Neurol. (Chicago) 20:378, 1969.
52. PROSENZ, P. Investigations on the filter capacity of the dog's brain. Arch. Neurol. (Chicago) 26:479, 1972.
53. RACE, D.; DEDICHEN, H. & SCHENK, W. G. Regional blood flow during dextran-induced normovolemic hemodilution in the dog. J. Thoracic & Cardiovasc. Surg. 53:578, 1967.
54. RAICHLE, M. E. & PLUM, F. Hyperventilation and cerebral blood flow. Stroke 3:566, 1972.
55. REES, J. E.; DUBOULAY. G. H.; BULL, J. W. D.; MARSHALL, J.; RUSSELL, R. W. & SYMON, L. The comparative analysis of isotope clearence curves in normal and ischemie brain. Stroke 2:444, 1971.
56. REGLI, F.; YAMAGUCHI, T. & WALTZ, A. G. Effects of acetazolamide on cerebral ischemia and infarction after experimental occlusion of middle cerebral artery. Stroke 2:456, 1971.
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Datas de Publicação

Publicação nesta coleção
15 Abr 2013
Data do Fascículo
Dez 1973

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ALLARDYCE, D. B.; YOSHIDA, S. H. & ASHMORE, P. G. The importance of microembolism in the pathogenesis of organ dysfunction caused by prolonged use of the pump oxygenator. J. Thoracic & Cardiovas. Surg. 52:706, 1966.

[2] 2. ARFEL, G.; WEISS, J. & DuBOUCHET, N. EEG findings during open heart surgery with extra-corporeal circulation. In Meyer, J. S. e Gastaut, H. Cerebral Anoxia and the Electroencephalogram, Charles C. Thomas, Springfield (Illinois), 1961.

[3] 3. BRAWLEY, B. W.; STRANDNESS Jr., E. & KELLY, W. A. The physiologic response to therapy in experimental cerebral ischemia. Arch. Neurol. (Chicago) 17:80, 1967.

[4] 4. BRENNAN, R. W.; PATTERSON, R. H. & KESSLER, J. Cerebral blood flow and metabolism during cardiopulmonary bypass: evidence of microembolic encephalopathy. Neurology (Minneapolis) 21:665, 1971.

[5] 5. BRIERLEY, J. B. Systemic hypotension: neurological and neuropathological aspects. In Modern Trends in Neurology. Vol. 5. Appleton-Century-Crofts, London, 1970, pág. 164.

[6] 6. BROOK, M. Patogenia dos acidentes vasculares cerebrais em função dos conhecimentos atuais sobre circulação regional do encéfalo. Resumo do V Congresso Brasileiro de Neurologia, São Paulo, Julho 1972.

[7] 7. CARTER, C. C.; EICHLING, J. O.; DAVIS, D. O. & PERPOGOSSIAN, M. M. Correlation of regional cerebral blood flow with regional oxygen uptake using O¹⁵ method. Neurology (Minneapolis) 22:755, 1972.

[8] 8. CLASEN, R. A.; PANDOLFI, S. & HASS, G. M. Interrupted hypothermia in experimental cerebral edema. Neurology (Minneapolis) 20:279, 1970.

[9] 9. FIESCHI, C.; AGNOLI, A.; BATTISTINI, N.; BOZZAO, L. & PRENCIPE, M. Derangement of regional cerebral blood flow and of its regulatory mechanisms in acute cerebrovascular lesions. Neurology (Minneapolis) 18:1166, 1968.

[10] 10. FIESCHI, C.; AGNOLI, A.; BATTISTINI, N. & BOZZAO, L. Regional cerebral blood flow in patients with brain infarcts. Arch. Neurol. (Chicago) 15:653, 1966.

[11] 11. FISCHER, E. G. & AMES, A. Studies on mechanisms of impairment of cerebral circulation following ischemia: effect of hemodilution and perfusion pressure. Stroke 3:538, 1972.

[12] 12. FIESCHER-WILLIAMS, M.; GOTTSCHALK, P. G. & BROWELL, J. N. Transient cortical blindness. Neurology (Minneapolis) 20:353, 1970.

[13] 13. GILMAN, S. Cerebral disorders after open-heart operations. New Engl. J. Med. 272:489, 1965.

[14] 14. GILROY, J.; BARNHART, M. I. & MEYER, J. S. Treatment of acute stroke with dextran 40. J.A.M.A. 210:293, 1969.

[15] 15. GINSBERG, M. D. & MYERS, R. E. The topography of impaired microvascular perfusion in the primate brain following total circulatory arrest. Neurology (Minneapolis) 22:998, 1972.

[16] 16. GOTTSTEIN, U. & PAULSON, O. B. The effect of intracarotid aminophyline infusion on the cerebral circulation. Stroke 3:560, 1972.

[17] 17. HARPER, A. M.; DESHMUK, V. D.; ROWAN, J. O. & JENNETT, B. The influence of sympathetic nervous activity on cerebral blood flow. Arch. Neurol. (Chicago) 27:1, 1972.

[18] 18. HARRISON, M. J. G. & RUSSELL, R. W. Effect of dexamethasone on experimental cerebral infarction in the gerbil. J. Neurol. Neurosurg. Psychiat. 35:520, 1972.

[19] 19. HASBROUCK, J. D. & RIGOR, B. M. The oxygen tension of cerebrospinal fluid during cardiopulmonary bypass. J. Thoracic & Cardiovac. Surg. 58:754, 1969.

[20] 20. HEKMATPANAH, J. Cerebral blood flow dynamics in hypotension and cardiac arrest. Neurology (Minneapolis) 23:174, 1973.

[21] 21. HOEDT-RASMUSSEN, K.; SKINHOJ, E.; PAULSON, O.; EWALD, J.; BJERRUM, J. K.; FAHRENKRUG, A. & LASSEN, N. A. Regional cerebral blood flow in acute apoplecy (the luxury perfusion syndrome of brain tissue). Arch. Neurol. (Chicago) 17:271, 1967.

[22] 22. JAFFE, M. E.; McHENRY, L. C. & GOLDBERG, H. I. Regional cerebral blood flow measurement with small probes. Neurology (Minneapolis) 20:225, 1970.

[23] 23. JAVID, H.; TUFO, H. M.; NAJAFI, H.; DYE, W. S.; HUNTER, J. A. & JULIAN O. C. Neurological abnormalities following open-heart surgery. J. Thoracic & Cardiovasc. Surg. 58:502, 1969.

[24] 24. KOGURE, K.; FUJISHIMA, M.; SCHEINBERG, P. & REINMUTH, O. M. Effects of changes in carbon dioxide pressure and arterial pressure on blood flow in ischemic regions of the brain in dogs. Circulation Research 24:557, 1969.

[25] 25. LASSEN, N. A. Cerebral blood flow and oxygen consumption in man. Physiological Reviews 19:183, 1959.

[26] 26. LASSEN, N. A. The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2:1113, 1966.

[27] 27. McHENRY Jr., L. C. Cerebral blood flow. New Engl. J. Med. 274:82, 1966.

[28] 28. McHENRY Jr., L. C. Cerebral vasodilator therapy in stroke. Stroke 3:686, 1972.

[29] 29. McHENRY, L. C.; GOLBERG, H. I.; JAFFE, M. E.; KENTON III, E. J.; WEST, J. W. & COOPER, E. S. Regional cerebral blood flow. Arch. Neurol. (Chicago) 27:403, 1972.

[30] 30. McHENRY, L. C.; JEFFE, M. E.; KAWAMURA, J. & GOLBERG, H. I. Effect of papaverine on regional blood flow in focal vascular disease of the brain. New Engl. J. Med. 282:1167, 1970.

[31] 31. MEYER, J. S.; CHARNEY, J. Z.; RIVERA, V. M. & MATHEW, N. T. Cerebral embolization: prospective clinical analysis of 42 cases. Stroke 2:541, 1971.

[32] 32. MEYER, J. S.; FUKUUCHI, Y.; SHIMAZU, K.; OHUCHI, T. & ERICSSON, A. D. Abnormal hemispheric blood flow and metabolism in cerebrovascular disease: therapeutic trials with 5% CO₂ inhalation, hyperventilation and intravenous infusion of THAM and mannitol Stroke 3:157, 1972.

[33] 33. MEYER, J. S.; FUKUUCHI, Y.; SHIMAZU, K.; OHUCHI, T. & ERICSSON, A. D. Effect of intravenous infusion of glycerol on hemispheric blood flow and metabolism in patients with acute cerebral infarction. Stroke 3:168, 1972.

[34] 34. MEYER, J. S.; GOTOH, F.; GILROY, J. & NARA, N. Improvement in brain oxygenation and clinical improvement in patients with strokes treated with papaverine hydrochloride. J.A.M.A. 194:957, 1965.

[35] 35. MEYER, J. S.; KANDA, T.; FUKUUCHI, Y.; SHIMAZU, K.; DENNIS, E. W. & ERICSSON, A. D. Clinical prognosis correlated with hemispheric blood flow in cerebral infarction. Stroke 2:383. 1971.

[36] 36. MEYER, J. S.; KANDA, T.; SHINOHARA, Y.; FUKUUCHI, Y.; SHIMAZU, K.; ERICSSON, A. D. & GORDON, W. H. Effect of hexabendine on cerebral hemispheric blood flow and metabolism. Neurology (Minneapolis) 21:691, 1971.

[37] 37. MEYER, J. S.; SAWADA, T.; KITAMURA, A. & TOYODA, M. Cerebral oxygen, glucose, lactate and pyruvate metabolism in stroke. Therapeutic considerations. Circulation 37:1036, 1968.

[38] 38. MEYER, J. S.; TERAURA, T.; MARX, P.; HASHI, K.; & SAKAMOTO, K. Brain swelling due to experimental cerebral infarction. Changes in vasomotor capacitance and effects of intravenous glycerol. Brain 95:833, 1972.

[39] 39. MILLER, J. R. & MYERS, R. E. Neurological effects of systemic circulatory arrest in the monkey. Neurology (Minneapolis) 20:715, 1970.

[40] 40. MILLER, J. R. & MYERS, R. E. Neuropathology of systemic circulatory arrest in adult monkeys. Neurology (Minneapolis) 22:888, 1972.

[41] 41. MILLIKAN, C. H. Reassessment of anticoagulant therapy in variou types of occlusive cerebrovascular disease. Stroke 2:201, 1971.

[42] 42. MILLIKAN, C. H. Summary of the eight Princeton Conference on cerebral vascular diseases (January 5-7, 1972, Nassau Tavern, Princeton, New Jersey). Stroke 3:105, 1972.

[43] 43. OLESEN, J. Total co₂, lactate and pyruvate in brain biopsies taken after freezing the tissue in situ. Acta Neurol. Scandinav. 46:141, 1970.

[44] 44. OLESEN, J. & PAULSON, O. B. The effect of intra-arterial papaverine on the regional cerebral blood flow in patients with stroke or intracranial tumor. Stroke 2:148, 1971.

[45] 45. OLESEN, J.; PAULSON, O. B. & LASSEN, N. A. Regional cerebral blood flow in man determined by the initial slope of the clearence of intra-arterially injected 133 Xe. Stroke 2:519, 1971.

[46] 46. PATTEN, B. M.; MENDELL, J.; BRUUN, B.; CURTIN, W. & CARTER, S. Double-blind study of the effects of dexamethasone on acute stroke. Neurology (Minneapolis) 22:377, 1972.

[47] 47. PATTERSON, R. H. & KESSLER, J. Microemboli during cardiopulmonary bypass detected by ultrasound. Surg. Gyn. .& Obst. 129:505, 1969.

[48] 48. PAULSON, G. W.; LOCKE, G. E. & YASHON, D. Cerebral spinal fluid lactic acid following circulatory arrest. Stroke 2:565, 1971.

[49] 49. PAULSON, O. B. Regional cerebral blood flow in apoplexy due to occlusion of the midle cerebral artery. Neurology (Minneapolis) 20:63, 1970.

[50] 50. PAULSON, O. B. Cerebral apoplexy (stroke): pathogenesis, pathophysiology and therapy as illustrated by regional blood flow measurements in the brain. Stroke 2:327, 1971.

[51] 51. POTCHEN, E. J.; DAVIS, D. O.; WHARTON, T.; HILL, R. & TAVERAS, J. M. Regional cerebral blood flow in man: a study of the xenon 133 washout method. Arch. Neurol. (Chicago) 20:378, 1969.

[52] 52. PROSENZ, P. Investigations on the filter capacity of the dog's brain. Arch. Neurol. (Chicago) 26:479, 1972.

[53] 53. RACE, D.; DEDICHEN, H. & SCHENK, W. G. Regional blood flow during dextran-induced normovolemic hemodilution in the dog. J. Thoracic & Cardiovasc. Surg. 53:578, 1967.

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Complicações neurológicas da cirurgia cardíaca: revisão sobre a patogenia e bases para tratamento

Neurological complications of heart surgery: a review about the pathogenesis and treatment bases

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