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Glycerol Infusion Versus Mannitol for Cerebral Edema: A Systematic Review and Meta-analysis. Clin Ther 2021; 43:637-649. [PMID: 33581877 DOI: 10.1016/j.clinthera.2021.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE For the treatment of cerebral edema, the use of glycerol, an osmotic agent, as well as mannitol, is popular in Asia. However, the relative therapeutic benefit of glycerol remains unknown. The goal of this study was to investigate the comparative efficacy and safety of glycerol infusion versus mannitol infusion for cerebral edema. METHODS A systematic search was performed in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, and Scopus for all eligible articles published before July 2020, with no restrictions on language. Two reviewers independently screened the articles, extracted data, and carefully assessed the quality of the evidence. FINDINGS Eight studies (6 clinical, 2 animal) were ultimately included in the qualitative analysis, and five were included in the quantitative analysis. Pooled analyses revealed nonsignificant differences in the successful control of cerebral edema (relative risk [RR], 0.97; 95% CI, 0.81-1.15). The combination therapy with glycerol led to a favorable trend in neurologic improvements. Regarding safety, glycerol was associated with a significantly lower risk of acute kidney injury (RR, 0.27; 95% CI, 0.11-0.69) and electrolyte disturbances (RR, 0.20; 95% CI, 0.06-0.64), as well as a lower possibility of rebound effects. No hemolysis was observed at the final follow-up. IMPLICATIONS Although the data are limited, compared with mannitol, glycerol shows a similar level of effectiveness, a more favorable safety profile, and promising neurologic improvement in individuals with cerebral edema. Additional research is needed to confirm these findings. PROSPERO CRD42020187702.
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Wang J, Ren Y, Wang SF, Kan LD, Zhou LJ, Fang HM, Fan H. Comparative efficacy and safety of glycerol versus mannitol in patients with cerebral oedema and elevated intracranial pressure: A systematic review and meta-analysis. J Clin Pharm Ther 2020; 46:504-514. [PMID: 33217016 DOI: 10.1111/jcpt.13314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Glycerol is thought to be superior to mannitol in the treatment of cerebral oedema and elevated intracranial pressure (ICP), particularly with safety concerns. However, the current evidence remains insufficient. Therefore, we aimed to compare the efficacy and safety of glycerol versus mannitol in this meta-analysis. METHODS PubMed, EMBASE, Web of Science, CENTRAL, China National Knowledge Infrastructure, Wanfang Database, Chongqing VIP information, ClinicalTrials.gov, and the reference lists of relevant articles were searched for randomized controlled trials comparing glycerol and mannitol in patients with brain oedema and elevated ICP. Two investigators independently identified the articles, assessed the study quality and extracted data. Data analyses were performed using RevMan software. RESULTS AND DISCUSSION Thirty trials involving 3144 patients met our inclusion criteria. Pooled data indicated that glycerol and mannitol had comparable effectiveness in controlling cerebral oedema (RR, 1.00; 95% CI, 0.97 to 1.03; p = .97), but the risks of acute kidney injury and electrolyte disturbances were significantly lower with glycerol (RR, 0.21; 95% CI, 0.16 to 0.27 and RR, 0.23; 95% CI, 0.17 to 0.30, respectively) than mannitol. Moreover, there seemed to be a lower probability of rebound ICP after the withdrawal of glycerol. Neither haemolysis nor elevated blood glucose levels were observed in the glycerol group. WHAT IS NEW AND CONCLUSION Regarding the balance between efficacy and safety, glycerol could be an effective and more tolerable alternative therapy for cerebral oedema and elevated ICP than mannitol, especially for high-risk populations of renal failure.
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Affiliation(s)
- Jia Wang
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Ren
- Department of Nephrology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Shuai-Fei Wang
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lian-Di Kan
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li-Juan Zhou
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hong-Mei Fang
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Fan
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Shim SY, Kim HS, Kim DH, Kim EK, Son DW, Kim BI, Choi JH. Induction of early meconium evacuation promotes feeding tolerance in very low birth weight infants. Neonatology 2007; 92:67-72. [PMID: 17356305 DOI: 10.1159/000100804] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Accepted: 12/05/2006] [Indexed: 01/08/2023]
Abstract
BACKGROUND A delay in reaching full enteral feeding is linked to poorer outcome in preterm neonates. Meconium retention has been viewed as a cause of bowel dysfunction in very low birth weight infants (VLBWI). Thus, adequate evacuation of meconium could help to promote feeding tolerance. OBJECTIVES Our goal was to determine the effect of the induction of early meconium evacuation on feeding tolerance in VLBWI. METHODS An observational study involving two subsequent periods was performed in inborn infants with birth weights of <1,500 g, before (control) and after (study) the induction of early meconium evacuation by routine glycerin enema. The total duration of these periods was from January 2003 to December 2005. To evaluate feeding tolerance, we measured time to achieve full enteral feeding. Complications such as sepsis and necrotizing enterocolitis were compared. RESULTS The study group achieved full enteral feeding significantly faster than the control group (hazard ratio (HR) = 2.9; 95% confidence interval (CI) = 1.8-4.8), and this effect was more definite in infants with a birth weight of <1,000 g (HR = 4.6; 95% CI = 1.9-11.1). The study group passed first meconium faster than the control group (median = 1.4 vs. 3.7 days; p < 0.001). Sepsis, especially as determined by positive culture in central venouscatheter, was significantly reduced in the study group (7.7 vs. 27.8%; p = 0.02). CONCLUSIONS The induction of early meconium evacuation had a significantly positive effect on feeding tolerance and sepsis prevention in VLBWI.
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Affiliation(s)
- So-Yeon Shim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Brain oedema is a major cause of early death after stroke. A 10% solution of glycerol is a hyperosmolar agent that is claimed to reduce brain oedema. OBJECTIVES To determine whether intravenous (I.V.) glycerol treatment in acute stroke, either ischaemic or haemorrhagic, influences death rates and functional outcome in the short or long term, and whether the treatment is safe. SEARCH STRATEGY The Cochrane Stroke Group trials register was searched (January 2003), and some trialists were personally contacted. SELECTION CRITERIA All completed, randomised and quasi-randomised, controlled, published and unpublished comparisons, evaluating clinical outcome in which I.V. glycerol treatment was initiated within the first days after stroke onset. DATA COLLECTION AND ANALYSIS Two reviewers independently applied the inclusion criteria, assessed the trial quality and extracted data and this was checked with all co-reviewers. Death from all causes, functional outcome, and adverse effects were analysed. MAIN RESULTS Eleven completed, randomised trials comparing I.V. glycerol and control were considered. Analysis of death during the scheduled treatment period for acute ischaemic and/or haemorrhagic stroke was possible in 10 trials where 482 glycerol treated patients were compared with 463 control patients. Glycerol was associated with a non-significant reduction in the odds of death within the scheduled treatment period (Odds Ratio (OR) 0.78, 95% Confidence Intervals (CI) 0.58 to 1.06). Among patients with definite or probable ischaemic stroke, glycerol was associated with a significant reduction in the odds of death during the scheduled treatment period (OR 0.65, 95% CI 0.44 to 0.97). However, at the end of the scheduled follow up period, there was no significant difference in the odds of death (OR 0.98, 95% CI 0.73 to 1.31). Functional outcome was reported in only two studies but there were non-significantly more patients who had a good outcome at the end of scheduled follow up (OR 0.73, 95% CI 0.37 to 1.42). Haemolysis seems to be the only relevant adverse effect of glycerol treatment. REVIEWERS' CONCLUSIONS This systematic review suggests a favourable effect of glycerol treatment on short term survival in patients with probable or definite ischaemic stroke but the confidence intervals were wide and the magnitude of the treatment effect may be only minimal. Due to the relatively small number of patients, and that the trials were performed in the pre-CT era, the results must be interpreted cautiously. The lack of evidence of benefit in long term survival does not support the routine or selective use of glycerol treatment in patients with acute stroke.
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Affiliation(s)
- Enrico Righetti
- USL 2Servizio di Neurologia e Ictus Via Cestellini PerugiaItaly06087
| | | | - Teresa Anna Cantisani
- Azienda Ospedaliera PerugiaNeurofisiopatologiaS. Andrea Delle FratteSan SistoPerugiaUMBRIAItaly06156
| | - Roberto Sterzi
- Azienda Ospedaliera Sant'AnnaDirettore UO NeurologiaVia Napoleona, 50ComoItaly22100
| | - Gudrun Boysen
- Bispebjerg HospitalDepartment of Neurology, University of CopenhagenBispebjerg Bakke 23DK 2400 Copenhagen NVDenmark
| | - Stefano Ricci
- USL 2Servizio di Neurologia e IctusVia Cestellini PerugiaItaly06087
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Righetti E, Celani MG, Cantisani T, Sterzi R, Boysen G, Ricci S. Glycerol for acute ischaemic stroke. Cochrane Database Syst Rev 2000:CD000096. [PMID: 11034673 DOI: 10.1002/14651858.cd000096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Infarct-related oedema following ischaemic stroke is thought to be a major cause of early death. Intravenous glycerol may reduce the oedema, increase cerebral blood flow and improve cerebral metabolism. OBJECTIVES The objective of this review was to assess the effect of glycerol in acute ischaemic stroke. SEARCH STRATEGY We searched the Cochrane Stroke Group trials register, Medline and Embase. SELECTION CRITERIA Randomised trials of intravenous glycerol compared with control in people with definite or presumed ischaemic stroke. Trials were included if treatment was initiated within the first four days of stroke onset. DATA COLLECTION AND ANALYSIS Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS Eight trials involving 649 people were included. Based on 454 patients in six trials, glycerol was associated with a decrease in deaths within 14 days of stroke onset (odds ratio of 0.58, 95% confidence interval 0.36 to 0.91). Based on 431 patients in five trials, there was a non-significant decrease in deaths within the first year of stroke onset (odds ratio of 0.82, 95% confidence interval 0.54 to 1.23). The effect of treatment on functional outcome was not clear. Haemolysis appeared to be the only adverse effect. REVIEWER'S CONCLUSIONS There is not enough evidence to evaluate glycerol treatment for people with acute ischaemic stroke.
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Affiliation(s)
- E Righetti
- Stroke Service, USL 2, Via Guerra 17, Perugia, ITALY, 06127.
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Abstract
The administration of osmotic agents is one of the principal strategies to lower elevated intracranial pressure (ICP) and to increase cerebral perfusion pressure. Of the 3 osmotic agents frequently used (mannitol, glycerol and sorbitol), each has characteristic advantages and disadvantages. In addition to renal filtration, sorbitol [elimination half-life (t1/2beta) approximately 1h] and glycerol (t1/2beta 0.2 to 1h) are metabolised, mainly by the liver. The risk of these compounds accumulating in patients with renal insufficiency is low. However, both compounds frequently affect glucose metabolism, leading to an increase in the serum glucose concentration. Mannitol is almost exclusively renally filtered and possesses the slowest elimination from serum (t1/2beta 2 to 4h). The t1/2beta of mannitol is markedly increased in patients with renal insufficiency, but it does not interfere with glucose metabolism. Entry into the cerebrospinal fluid (CSF) is highest with glycerol [CSF: serum ratio of the areas under the concentration-time curves (AUC(CSF): AUCs) approximately 0.25], intermediate with mannitol (AUC(CSF): AUCs approximately 0.15) and lowest with sorbitol (AUC(CSF): AUCs approximately 0.10). The elimination of all osmotic agents from the CSF compartment is substantially slower than from serum. During the elimination phase, the CSF-to-serum osmotic gradient is temporarily reversed. This is one cause of the paradoxical rise of ICP above the pretreatment level sometimes observed with osmotherapeutics. The ability of mannitol, glycerol and sorbitol to lower elevated ICP has been extensively documented. However, whether the use of osmotic agents, particularly with repeated application, improves outcome remains unproven. Therefore, these agents should only be used to treat manifest elevations of ICP, not for prophylaxis of brain oedema.
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Affiliation(s)
- R Nau
- Department of Neurology, University of Göttingen, Germany.
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Biestro A, Alberti R, Galli R, Cancela M, Soca A, Panzardo H, Borovich B. Osmotherapy for increased intracranial pressure: comparison between mannitol and glycerol. Acta Neurochir (Wien) 1997; 139:725-32; discussion 732-3. [PMID: 9309287 DOI: 10.1007/bf01420045] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Osmotic agents are still the most common treatment for controlling intracranial hypertension (ICH). Mannitol, glycerol, sorbitol, and hypertonic serum saline are the agents currently available. This work was designed to compare mannitol and glycerol in a similar population of brain injured patients, randomly divided into two groups of eight. The following mean day parameters were obtained: number of infusions, hydric balance, mean arterial pressure (MAP), and intracranial pressure (ICP). Cerebral perfusion pressure (CPP) was calculated. Brain computed tomographies (CT) were obtained on arrival, at follow-up whenever justified and at discharge. For comparison of both groups a modified therapeutic intensity level (mTIL) was used. Both agents induced a statistically equally effective decrease on ICP and increase on CPP evaluated at one and two hours post infusion but the mean day mTIL showed a statistically significant difference in favour of glycerol. The possible explanations of this difference are discussed. According to our results mannitol would be most indicated as a bolus to control sudden rises in ICP whereas glycerol would be most indicated as a basal treatment.
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Affiliation(s)
- A Biestro
- Department of Intensive Medicine, Hospital de Clínicas, Faculty of Medicine, Montevideo, Uruguay
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Abstract
Osmotherapy with compounds such as mannitol has become a mainstay of neurologic and neurosurgical intensive care. Elevated intracranial pressure is the most common indication. A substantive debate remains as to the appropriate timing of administration and the optimal fluid management protocol, and experts disagree about the clinically relevant mechanisms of action of osmotic diuretics. This article briefly summarizes the basic literature on the physical actions of mannitol, addresses commonly asked questions, and highlights some of the controversies that arise at the bedside.
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Affiliation(s)
- R P Paczynski
- Neurology and Neurosurgery Intensive Care Unit, Washington University Medical Center, St. Louis, Missouri, USA
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Abstract
1. Although the effect of glycerol on reducing intracranial pressure has been widely investigated, only a few studies have reported its dehydrating effect on brain oedema caused by infarction, ischaemia, microembolism and cold injury, but none on traumatic oedema. In this study the effects of glycerol (1 g/kg, i.v. bolus infusion at a rate of 0.04 g/kg per min) on traumatic and cryogenic cerebral oedema and on normal brain were compared in the anaesthetized dog. The tissue water content was measured with the gravimetric method. 2. Oedema resulting from mechanical trauma was initiated 4 h prior to treatment with glycerol (8 dogs) or vehicle (5 dogs) by closed head contusion with fixed force under general anaesthesia. Tissue samples underneath the region of contusion were taken, before and 1 h after infusion of glycerol or vehicle, for the measurement of water content. 3. Glycerol infusion decreased the water content in white matter of the traumatic brain model from 76.54 +/- 1.70% to 70.73 +/- 1.54% (P < 0.001). In normal brain the reduction was from 68.42 +/- 0.48% to 65.36 +/- 0.39% (P < 0.001). Neither vehicle nor glycerol infusion resulted in significant changes in specific gravity of the gray matter. 4. Cryogenic oedema was initiated 3 h prior to the infusion of glycerol or vehicle by applying unilaterally a brass conical cup (bottom diameter 1 cm) filled with dry ice-acetone (-65 degrees C) to the exposed dura for 1 min. The contralateral hemisphere, which was not subjected to cold injury, was used for determination of water content of normal gray and white matter. 5. Glycerol infusion decreased the water content in the white matter of the cold-injured region from 75.38 +/- 0.69% to 72.57 +/- 0.58% (P < 0.001). In the normal white matter the reduction was from 68.63 +/- 0.34% to 65.48 +/- 0.49% (P < 0.001). 6. Our data indicate that glycerol decreases water content of the white matter in traumatic and cold-injured oedematous brain as well as in normal brain.
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Affiliation(s)
- J Y Wang
- Department of Physiology, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Yu YL, Kumana CR, Lauder IJ, Cheung YK, Chan FL, Kou M, Fong KY, Cheung RT, Chang CM. Treatment of acute cortical infarct with intravenous glycerol. A double-blind, placebo-controlled randomized trial. Stroke 1993; 24:1119-24. [PMID: 8342183 DOI: 10.1161/01.str.24.8.1119] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND PURPOSE This clinical trial investigates the effectiveness of intravenous glycerol therapy in patients with acute cortical infarction in whom intracerebral hemorrhage was rigorously excluded. METHODS Within 48 hours of symptoms from their first ischemic stroke, 113 hospital inpatients were randomized into the trial, provided that hemorrhage was excluded by computed tomography and informed consent was obtained. Patients were stratified into alert, semicoma, and coma groups using the Glasgow Coma Scale. Treatment was allocated according to a double-blind, randomized protocol; 56 patients received 500 mL of 10% glycerol in saline over 4 hours on 6 consecutive days, and 57 patients received corresponding placebo treatment with saline. Using a variety of objective scoring systems, patient follow-up was up to 6 months. RESULTS Corresponding measures of outcome in the glycerol and placebo groups were similar. At 6 months, respective mortality rates were 17 of 56 and 16 of 57, and mean +/- SD improvements in scores were 9.98 +/- 14.40 vs 10.51 +/- 12.68 (long-term), 1.12 +/- 7.20 vs 1.57 +/- 6.30 (prognostic), -1.94 +/- 5.53 vs -2.06 +/- 5.34 (Glasgow Coma Scale), and 21.72 +/- 23.40 vs 11.94 +/- 18.10 (Barthel Index rating in survivors). Hemolysis (generally subclinical) was the only adverse effect. CONCLUSIONS There was no clinically or statistically significant difference in outcome between the groups; a trend toward greater functional recovery among survivors was evident after treatment with glycerol.
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Affiliation(s)
- Y L Yu
- Department of Medicine, University of Hong Kong
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Yu YL, Kumana CR, Lauder IJ, Cheung YK, Chan FL, Kou M, Chang CM, Cheung RT, Fong KY. Treatment of acute cerebral hemorrhage with intravenous glycerol. A double-blind, placebo-controlled, randomized trial. Stroke 1992; 23:967-71. [PMID: 1615546 DOI: 10.1161/01.str.23.7.967] [Citation(s) in RCA: 93] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Hitherto, treatment of acute cerebral hemorrhage with intravenous glycerol has not been evaluated in rigorous clinical studies with sufficient patient numbers. METHODS We undertook a double-blind, stratified and randomized, placebo-controlled clinical trial. Only patients with a first stroke admitted to the hospital within 24 hours after onset of symptoms were recruited, provided computed tomography confirmed hemorrhage and informed consent was obtained. After stratification into alert, semicoma, and coma subgroups using the Glasgow Coma Scale, 107 patients received active treatment (500 ml of 10% glycerol in saline by intravenous infusion over 4 hours on 6 consecutive days) and 109 were given corresponding saline treatment. Using a variety of objective scoring systems, patients were followed up for up to 6 months. RESULTS At follow-up, all measures of outcome in the treated and control groups were very similar. At 6 months, respective mortality rates were 37 of 107 and 33 of 109. Corresponding mean +/- SD improvements in Scandinavian Stroke Study Group scores were 8.35 +/- 16.9 versus 11.55 +/- 15.6 (long-term) and 0.64 +/- 7.3 versus 2.40 +/- 6.9 (prognostic), and improvements in the Barthel Index ratings were 10.72 +/- 24.7 versus 13.95 +/- 23.3, respectively. Glasgow Coma Scale score improvements in the survivors were 0.81 +/- 1.5 and 1.16 +/- 1.7 in the treated and control groups, respectively. Hemolysis (generally subclinical) was the only adverse effect of glycerol noted. CONCLUSIONS In the absence of any clinically or statistically significant difference in outcome between the treated and control groups, this trial provides no justification for glycerol therapy following acute cerebral hemorrhage.
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Affiliation(s)
- Y L Yu
- Department of Medicine, University of Hong Kong
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Sharma P, Nag D, Atam V, Seth PK, Khanna VK. Platelet aggregation in patients with Parkinson's disease. Stroke 1991; 22:1607-8. [PMID: 1962340 DOI: 10.1161/01.str.22.12.1607] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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