PubMed Health⌕ Search

Biomedical subjects

Robyn L McClelland

Publications and source records attributed to Robyn L McClelland.

At least 37 records · Page 2Linked to original sources
PubMed2005

Postoperative stupor and coma.

OBJECTIVES: To identify predictive factors for postoperative coma or stupor and to examine the value of neuroimaging techniques in elucidating structural brain damage. PATIENTS AND METHODS: We performed a case-control study of surgical patients admitted to a Mayo Clinic-affiliated hospital. We studied preoperative comorbidity, intraoperative hypotension, and postoperative data in patients with postoperative stupor or coma and compared the characteristics with control patients (surgical intensive care unit patients with neurologic consultations for other reasons). RESULTS: A total of 35 patients with stupor or coma after surgery and 31 control patients participated in this study. Comatose patients were older (P=.004) and had significantly more presurgical comorbidity (P<.001), cardiovascular surgical procedures (P<.001), and intraoperative hypotension (P=.03). Adjusted for age and comorbidity, intraoperative hypotension remained statistically significant but not after adjusting for cardiovascular surgery. Of the 34 computed tomograms obtained, 41% showed abnormal results; of the 12 magnetic resonance images obtained, 58% showed abnormal results. Both showed primarily infarctions. In 4 patients with normal computed tomographic results, magnetic resonance imaging showed multiple territorial infarctions. CONCLUSION: Prior comorbidity, older age, intraoperative hypotension, and cardiovascular surgery may predispose patients to postoperative coma. Widespread structural ischemic brain damage was often documented by neuroimaging. Metabolic causes for coma were uncommon.

Adult↗
PubMed2004

Predictors of cerebral infarction in aneurysmal subarachnoid hemorrhage.

BACKGROUND: Clinical and radiologic predictors of cerebral infarction occurrence and location after aneurysmal subarachnoid hemorrhage have been seldom studied. METHODS: We evaluated all patients admitted to our hospital with aneurysmal subarachnoid hemorrhage between 1998 and 2000. Cerebral infarction was defined as a new hypodensity located in a vascular distribution on computed tomography (CT) scan. RESULTS: Fifty-seven of 143 patients (40%) developed a cerebral infarction. On univariate analysis, occurrence of cerebral infarction was associated with a worse World Federation of Neurological Surgeons grade (P=0.01), use of ventriculostomy catheter (P=0.01), preoperative vasospasm (P=0.03), surgical clipping (P=0.02), symptomatic vasospasm (P<0.01), and vasospasm on transcranial Doppler ultrasonography (TCD) or repeat angiogram (P<0.01). On multivariable analysis, only presence of symptoms ascribed to vasospasm (P<0.01) and evidence of vasospasm on TCD or angiogram predicted cerebral infarction (P<0.01). TCD and angiogram agreed on the diagnosis of vasospasm in 73% of cases (95% CI, 63% to 81%), but the diagnostic accuracy of this combination of tests was suboptimal for the prediction of cerebral infarction occurrence (sensitivity, 0.72; specificity, 0.68; positive predictive value, 0.67; negative predictive value, 0.72). Location of the cerebral infarction on delayed CT was predicted by neurological symptoms in 74%, by aneurysm location in 77%, and by angiographic vasospasm in 67%. CONCLUSIONS: Evidence of vasospasm on TCD and angiogram is predictive of cerebral infarction on CT scan but sensitivity and specificity are suboptimal. Cerebral infarction location cannot be predicted in one quarter to one third of patients by any of the studied clinical or radiological variables.

Adult↗
PubMed2004

Relation of metformin treatment to clinical events in diabetic patients undergoing percutaneous intervention.

Diabetic patients undergoing coronary interventions have worse clinical and angiographic outcomes than do patients without diabetes. Metformin, an insulin sensitizer, may decrease the occurrence of these outcomes. Diabetic patients in the Prevention of Restenosis with Tranilast and its Outcomes Trial were identified through their medical records (n = 2,772). In this trial, 1,110 diabetic patients received nonsensitizer therapy (insulin and/or sulfonylureas) and 887 received sensitizer therapy (metformin with or without additional therapy). Logistic regression was used to obtain odds ratios (ORs) (sensitizer vs nonsensitizer therapy) of any clinical event (death, myocardial infarction, or ischemia-driven target vessel revascularization) and adjusted for multiple risk factors. Multivariate analysis showed no effect of lesion characteristics on clinical outcomes. Compared with patients on nonsensitizer therapy, those on sensitizer therapy showed an adjusted OR of 0.72 (95% confidence interval [CI] 0.57 to 0.91, p = 0.005) for any clinical event. The differences between the nonsensitizer therapy group and the sensitizer group were attributable mainly to decreased rates of death (OR 0.39, 95% CI 0.19 to 0.77, p = 0.007) and myocardial infarction (OR 0.31, 95% CI 0.15 to 0.66, p = 0.002). In our retrospective analysis, use of metformin in diabetics undergoing coronary interventions appeared to decrease adverse clinical events, especially death and myocardial infarction, compared with diabetic patients treated with nonsensitizer therapy.

Angioplasty, Balloon, Coronary↗
PubMed2004

Clinical and angiographic predictors of restenosis after percutaneous coronary intervention: insights from the Prevention of Restenosis With Tranilast and Its Outcomes (PRESTO) trial.

BACKGROUND: Restenosis prediction from published studies is hampered by inadequate sample size and incomplete angiographic follow-up. The prediction of restenosis with the existing variables is poor. The aim of the present study was to include the clinical and angiographic variables commonly associated with angiographic restenosis and develop a prediction model for restenosis from the PRESTO database. METHODS AND RESULTS: This study included 1312 patients with a single lesion enrolled in the angiographic substudy of the PRESTO trial. We constructed 2 risk scores. The first used preprocedural variables (female gender, vessel size [< or =2.5 mm, 2.5 to 3 mm, 3 to 3.5 mm, 3.5 to 4 mm, >4 mm], lesion length >20 mm, diabetes, smoking status, type C lesion, any previous percutaneous coronary intervention [PCI], and unstable angina) derived from previous studies. Estimated restenosis rates and corresponding variability for each possible level of the resultant risk score were obtained via bootstrapping techniques. The area under the receiver-operator characteristic (ROC) curve was 0.63, indicating modest discriminatory ability to predict restenosis. The second approach constructed a multiple logistic regression model considering significant univariate clinical and angiographic predictors of restenosis identified from the PRESTO database (treated diabetes mellitus, nonsmoker, vessel size, lesion length, American College of Cardiology/American Heart Association type C lesion, ostial location, and previous PCI). The area under the ROC curve for this risk score was also 0.63. CONCLUSIONS: The preprocedural clinical and angiographic variables from available studies and from the PRESTO trial have only modest predictive ability for restenosis after PCI.

Aged↗
PubMed2004

Quality of life is favorable for most patients with multiple sclerosis: a population-based cohort study.

BACKGROUND: Quality of life (QOL) is becoming an increasingly important factor in measurement of disease impact as well as an outcome measure in clinical trials. OBJECTIVES: To study the QOL of patients with multiple sclerosis (MS) in a population-based prevalence cohort and compare it with the general US population. DESIGN: Population-based prevalence cohort. SETTING: Olmsted County, Minn, population. PARTICIPANTS: All patients with definite MS (N = 201) alive and residing in Olmsted County on December 1, 2000. INTERVENTION: None. MAIN OUTCOME MEASURES: The expanded disability status scale (EDSS) and the Multiple Sclerosis Quality of Life Health Survey (MSQOL-54), which consisted of Short Form 36 (SF-36) with an additional 18 items pertinent to MS. RESULTS: The MSQOL-54 form was completed by 185 patients. Patients with MS had worse scores than the general US population with respect to physical functioning, vitality, and general health dimensions of the SF-36 QOL measure. Many QOL domains (pain, role emotional, mental health, and social functioning) were, however, similar for the 2000 MS cohort compared with the general US population. Duration of MS and EDSS score correlated significantly with physical functioning (P<.001). The QOL correlation with EDSS score was less than expected. No significant difference in the scores for the 8 QOL dimensions were found for patients with quick vs slow progression (quick progression defined as <5 years from onset to EDSS score of 3). The majority of patients with MS (77%) were mostly satisfied or delighted with their QOL. CONCLUSION: Though MS can cause significant disability, most patients with MS in the Olmsted County prevalence cohort continue to report a good QOL.

Activities of Daily Living↗
PubMed2004

Clinical implications of benign multiple sclerosis: a 20-year population-based follow-up study.

In 2001, we followed up all patients from the 1991 Olmsted County Multiple Sclerosis (MS) prevalence cohort. We found that the longer the duration of MS and the lower the disability, the more likely a patient is to remain stable and not progress. This is particularly powerful for patients with benign MS with Expanded Disability Status Scale score of 2 or lower for 10 years or longer who have a greater than 90% chance of remaining stable. This is important because these patients represent 17% of the entire prevalence cohort. These data should assist in the shared therapeutic decision-making process of whether to start immunomodulatory medications.

Cohort Studies↗
PubMed2004

Prevalence of tremor in multiple sclerosis and associated disability in the Olmsted County population.

We applied a clinical tremor rating scale and measures of disability to 200 of 201 multiple sclerosis patients from a prevalence cohort in Olmsted County, Minnesota. In a community-based sample, tremor was found clinically in 51 (25%) patients, although only 6 (3%) patients had severe tremor. Within the population as a whole, tremor was strongly associated with impairment disability and handicap.

Adolescent↗
PubMed2004

Endothelial nitric oxide synthase gene polymorphisms predict susceptibility to aneurysmal subarachnoid hemorrhage and cerebral vasospasm.

Rupture of an intracranial aneurysm (subarachnoid hemorrhage) is a potentially devastating condition frequently complicated by delayed cerebral ischemia from sustained contraction of intracranial arteries (cerebral vasospasm). There is mounting evidence linking the formation of intracranial aneurysms and the pathogenesis of post-subarachnoid hemorrhage vasospasm to aberrant bioavailability and action of the vasodilator molecule nitric oxide generated by isoforms of nitric oxide synthase. In humans, the gene encoding the endothelial isoform of nitric oxide synthase (eNOS) is known to be polymorphic, with certain polymorphisms associated with increased cardiovascular disease susceptibility. In this prospective clinical study involving 141 participants, we used gene microarray technology to demonstrate that the eNOS gene intron-4 27-base pair variable number tandem repeat polymorphism (eNOS 27 VNTR) predicts susceptibility to intracranial aneurysm rupture, while the eNOS gene promoter T-786C single nucleotide polymorphism (eNOS T-786C SNP) predicts susceptibility to post-subarachnoid hemorrhage vasospasm. We believe that genetic information such as this, which can be obtained expeditiously at the time of diagnosis, may be used as a helpful adjunct to other clinical information aimed at predicting and favorably modifying the clinical course of persons with intracranial aneurysms.

Adult↗
PubMed2004

A pilot study of dendroaspis natriuretic peptide in aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Hypovolemia after aneurysmal subarachnoid hemorrhage (SAH) may be mediated by natriuretic peptides and can further impair cerebral perfusion in dysautoregulated and vasospastic arterial territories. Dendroaspis natriuretic peptide (DNP), derived from the venom of Dendroaspis augusticeps, the Green Mamba snake, has recently been discovered in human plasma and atrial myocardium. There is no information regarding the presence or putative role of this peptide in patients with aneurysmal SAH. METHODS: A sensitive and specific DNP radioimmunoassay was performed on venous blood samples obtained on post-SAH Days 1, 3, and 7 from 10 consecutive SAH patients (cases) and randomly from 9 healthy volunteers (controls). Clinical and laboratory data, including daily serum sodium concentration and fluid balance, were collected prospectively up to 7 days after the ictus. RESULTS: Increase in plasma DNP levels occurred in five (63%) of eight patients who had DNP levels measured on Days 1 and 3 (mean increase, 29%). An increase in DNP level was significantly associated with development of a negative fluid balance (P = 0.003) and hyponatremia (P = 0.008). Three (75%) of the four patients who developed cerebral vasospasm during this study experienced an increase in DNP levels from Days 1 to 3. CONCLUSION: The present study is the first to find a significant association between elevated levels of DNP, a new member of the natriuretic peptide family, and the development of diuresis and natriuresis in patients with aneurysmal SAH. Our findings warrant further investigation by means of a large-scale, prospective, case-control study.

Adult↗
PubMed2004

Serum magnesium levels as related to symptomatic vasospasm and outcome following aneurysmal subarachnoid hemorrhage.

INTRODUCTION: Recent evidence suggests that magnesium may be neuroprotective in the setting of cerebral ischemia, and therapeutic magnesium infusion has been proposed for prophylaxis and treatment of delayed ischemic neurological deficit (DIND) resulting from vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). We studied the association between serum magnesium levels, the development of DIND, and the outcomes of patients with SAH. METHODS: We studied 128 consecutive patients with aneurysmal SAH treated at our institution between 1990 and 1997 who had a serum magnesium level measured at least once during the acute phase of their hospitalization. Delayed ischemic neurological deficit was defined as severe (major focal deficit or coma), moderate (incomplete focal deficit or decreased sensorium without coma), or none. RESULTS: There was no significant difference in mean, minimum, or maximum serum magnesium levels between patients with and without DIND (1.93, 1.83, 2.02 versus 1.91, 1.84, 1.97 mg/dL, respectively). Similarly, no difference was found in mean serum magnesium levels among patients with severe (1.94 mg/dL), moderate (1.92 mg/dL), or no DIND (1.91 mg/dL). Analyses of serum magnesium levels before (0-4 days following SAH), during (4-14 days following SAH), and after (greater than 14 days following SAH) the period of highest risk for vasospasm revealed no association with the development or severity of DIND. Permanent deficit or death resulting from vasospasm and Glasgow Outcome Scale score at longest follow-up were similarly unaffected by serum magnesium levels overall or during any time interval. Forty (31.5%) patients were hypomagnesemic (less than 1.7 mg/dL) during hospitalization, but no difference in outcome (p = 0.185) or development of DIND (p = 0.785) was found when compared to patients with normal (1.7-2.1 mg/dL) or high (greater than 2.1 mg/dL) magnesium serum levels. CONCLUSION: We identified no relationship between serum magnesium levels and the development of DIND or outcome following aneurysmal SAH. Based on these data, magnesium supplementation to normal or high-normal physiological ranges seems unlikely to be beneficial for DIND resulting from vasospasm. However, no inference can be made regarding the value of therapeutic infusion of magnesium to supraphysiological levels.

Adult↗
PubMed2004

Cost of treating high-risk symptomatic carotid artery stenosis: stent insertion and angioplasty compared with endarterectomy.

OBJECT: Definitive data characterizing the safety and efficacy of carotid angioplasty with stent placement (CAS) for symptomatic, occlusive carotid artery (CA) disease require further refinements and standardization of techniques as well as large prospective studies on a par with the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Despite the absence of such data, many surgeons have performed angioplasty and stent placement in patients with clinical or anatomical features known to add significant perioperative risk and capable of disqualifying the patients from participation in NASCET: There exists no cost analysis comparing high-risk endarterectomy with percutaneous angioplasty and stent insertion. METHODS: Forty-five patients (29 men and 16 women) with high-risk, symptomatic CA stenosis have been treated with CAS at the authors' institution since 1996. Indications for this procedure included symptomatic recurrent stenosis following CA endarterectomy (CEA), active coronary disease, high CA bifurcation, and severe medical comorbidities. A longstanding CEA computer database was screened for control patients with similar risk factors; 391 patients (276 men and 115 women) were identified. Actual cost data, duration of hospital stay, and relevant clinical data from the time of treatment until hospital discharge were collected in each patient. The median total cost of CAS was dollar 10,628, whereas that for CEA was dollar 10,148 (p = 0.495). CONCLUSIONS: In patients with high-risk, NASCET-ineligible CA stenosis there was no overall statistically significant cost difference between CEA and CAS. Given that there may not be a cost advantage for either procedure, procedural risk, efficacy, and durability should be key factors in determining the optimal treatment strategy.

Aged↗
PubMed2004

Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage.

OBJECT: Previous studies have indicated an increased incidence of death in patients with subarachnoid hemorrhage (SAH) who are currently receiving anticoagulation therapy. The significance of previous aspirin use in patients with SAH is unknown. The authors analyzed the effects of prior aspirin use on clinical course and outcomes following aneurysmal SAH. METHODS: The medical records of 305 patients with angiogram-confirmed aneurysmal SAH who consecutively presented to our institution between 1990 and 1997 within 7 days of ictus were analyzed. Twenty-nine (9.5%) of these patients had a history of regular aspirin use before onset of the SAH. The Glasgow Outcome Scale (GOS) was used to measure patient outcome at the longest available follow up. Aspirin users were older on average than nonusers (59 years of age compared with 53 years; p = 0.018). The mean admission Hunt and Hess grades of patients with and without aspirin use were similar (2 compared with 2.3; p = 0.51). Two trends, which did not reach statistical significance, were observed. 1) The rebleeding rate in aspirin users was 14.3%, compared with a 4.7% rebleeding rate in nonusers (p = 0.06). 2) Permanent disability from vasospasm was less common among aspirin users (23% compared with 50%; p = 0.069). Outcomes did not differ between aspirin users and nonusers (mean GOS Score 3.83 compared with GOS Score 3.86, respectively; p = 0.82). CONCLUSIONS: Despite trends indicating increased rebleeding rates and a lower incidence of permanent disability due to delayed ischemic neurological deficits, there was no significant effect of previous aspirin use on overall outcome following aneurysmal SAH. Based on these preliminary data, the presence of an intracranial aneurysm is not a strict contraindication to aspirin use.

Adult↗
PubMed2004

Cardiopulmonary resuscitation in critically ill neurologic-neurosurgical patients.

OBJECTIVES: To establish the rate of successful cardiopulmonary resuscitation (CPR) and to study outcome predictors in patients who experienced in-hospital cardiac arrest after being admitted to the neurologic-neurosurgical intensive care unit (ICU) with a primary neurologic diagnosis. PATIENTS AND METHODS: We identified patients admitted to the neurologic-neurosurgical ICU between 1994 and 2001 who experienced in-hospital cardiac arrest and received CPR. Functional outcome was assessed using the modified Rankin scale. RESULTS: During the study period, 38 consecutive patients experienced in-hospital cardiac arrest and received CPR. The median age of the patients was 65 years (range, 16-81 years), and the mean interval from admission to CPR was 12 days (range, 3 hours to 47 days). Acute intracranial disease was present in 32 patients (84%). Twenty-one patients (55%) were in the ICU at the time of the cardiac arrest; cardiac arrests in the wards occurred at a mean interval of 9 days (range, 1-45 days) after ICU discharge. Cardiopulmonary resuscitation achieved return of spontaneous circulation in 23 patients (61%). Seven patients (18%) were discharged from the hospital, 5 of whom later achieved a modified Rankin scale score of 2 or lower. Cardiac arrest after a deteriorating clinical course resulted in uniformly fatal outcomes. Duration of CPR shorter than 5 minutes and CPR in the ICU were associated with survival and good functional recovery. CONCLUSIONS: Cardiopulmonary resuscitation is a worthwhile procedure in severely ill neurologic-neurosurgical patients, regardless of the patient's age. However, the outcome after CPR appears much worse in patients with a prior deteriorating clinical course.

Adolescent↗
PubMed2003

Endothelial nitric oxide synthase T-786C single nucleotide polymorphism: a putative genetic marker differentiating small versus large ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Anecdotal evidence exists for at least 2 subpopulations of intracranial saccular aneurysms, namely, those that may form rapidly and rupture when small versus those that enlarge slowly and may rupture particularly when > or =10 mm in diameter. We sought to determine whether the endothelial nitric oxide synthase (eNOS) T-786C single nucleotide polymorphism (SNP), implicated in cardiovascular disease susceptibility, could facilitate differentiation between small (< or =5 mm) versus large (> or =10 mm) ruptured aneurysms. METHODS: In accordance with institutional guidelines, clinical data were recorded prospectively and genomic DNA was isolated from blood samples obtained from 52 aneurysmal subarachnoid hemorrhage (SAH) patients (cases) and 90 randomly selected controls. Samples were assayed for eNOS gene promoter T-786C SNP with the use of gene microarray technology. Statistical analyses included multiple logistic regression. RESULTS: Although there was no difference in genotype distributions between cases and controls, all 13 patients with large aneurysms were (T/C) heterozygous for the polymorphism, while 9 of 22 patients (41%) with small aneurysms were (T/T or C/C) homozygous (P=0.01). The mean (+/-SD) ruptured aneurysm diameter among all heterozygotes (8.5+/-5.2 mm) was significantly greater than that for C/C (6.0+/-2.3 mm) or T/T (4.7+/-1.8 mm) homozygotes (P=0.04). With the use of multivariate analysis, heterozygosity remained significantly associated with aneurysm size > or =10 mm (P=0.03). CONCLUSIONS: The eNOS T-786C SNP distinguishes genetically between small and large ruptured aneurysms. Although not predictive of SAH in the population at large, our data suggest that among persons with known intracranial aneurysms, eNOS T-786C genotype may be a factor influencing the size at which an aneurysm ruptures, a finding that should be taken into consideration along with other anatomic features of the aneurysm.

Age Distribution↗
PubMed2003

Stroke risk in anticoagulated patients with atrial fibrillation undergoing endoscopy.

OBJECTIVE: To determine the risk of stroke in anticoagulated patients with atrial fibrillation (AF) when anticoagulation is adjusted for bronchoscopy, gastroscopy, or colonoscopy, and to identify factors that could modify this risk. METHODS: The authors reviewed patients with AF undergoing endoscopies between 1995 and 2001, with specific analysis of patients with AF in whom anticoagulation was adjusted for the procedures. The authors calculated the stroke rate within 30 days of the procedures. RESULTS: Twelve strokes occurred in 987 patients undergoing 1,137 procedures (1.06%/procedure). The risk ranged from 0.31% for patients with nonvalvular AF undergoing routine procedures to 2.93% for complex patients undergoing endoscopies combined with other procedures or with comorbid illnesses. Patients with stroke were more likely to be complex (7/12 vs 219/975, p = 0.04); to be older than 80 years (6/12 vs 187/975, p = 0.017); to have a history of stroke (7/12 vs 194/975, p = 0.004), hypertension (10/12 vs 508/975, p = 0.04), or hyperlipidemia (9/12 vs 334/975, p = 0.005); or to have a family history of vascular disease (10/12 vs 502/975, p = 0.039). CONCLUSIONS: The risk of stroke in patients with AF whose anticoagulation is adjusted for endoscopies is low, but almost tenfold higher in patients with complex clinical situations. Age, history of stroke, hypertension, hyperlipidemia, and family history of vascular disease may increase the risk of stroke.

Age Factors↗
PubMed2003

Cause is the main predictor of outcome in patients with pontine hemorrhage.

BACKGROUND: Pontine hemorrhages frequently lead to death or severe disability. Predictors of early mortality have been previously described but little is known about the factors influencing long-term disability. OBJECTIVE: Determine clinical predictors of long-term outcome in a large hospital series of patients with acute pontine hemorrhage. METHODS: Review of all patients with acute pontine hemorrhage admitted to a single tertiary center from 1990 to 2002 who underwent a diagnostic workup including brain magnetic resonance imaging (MRI). Long-term outcome was rated using the modified Rankin Scale (mRS) score at the time of the last follow-up. Odds ratios (ORs) for predictive factors were calculated using univariate and multivariable logistic regression analysis. Level of significance was established at p < 0.01. RESULTS: We identified 44 consecutive patients with acute pontine hemorrhage. Twenty-four patients had primary hemorrhages (no cause other than hypertension). Arteriovenous or cavernous malformations were documented by brain MRI in 20 patients. Patients with primary hemorrhages had worse Glasgow Coma Scale sum scores (p = 0.01) and more unfavorable CT patterns (p = 0.005) at presentation. Eighteen percent of the patients died in the hospital. Mean follow-up among survivors was 20 months (range 3-144 months). Twenty-two percent of the patients remained severely disabled (mRS greater than 2) at 3 months and at the time of the last follow-up. All deaths occurred in patients with primary pontine hemorrhage. Poor outcome (death or severe disability) was more frequent in patients with primary hemorrhages when compared with patients harboring cavernous malformations (62 versus 5%; p < 0.01). Primary hemorrhage was the only independent predictor of poor outcome in multivariable regression analysis (OR 12; p = 0.029). CONCLUSIONS: Cause is a main predictor of clinical and radiological severity at presentation and outcome in patients with pontine hemorrhage. The first episode of hemorrhage in patients with brainstem cavernous malformations is usually benign. Pontine hemorrhage associated with prior hypertension is much more devastating.

Adolescent↗