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age of blood from the ventricles, shunting of the ventricles in cases of secondary hydrocephalus due to obstruction of the third ventricle or aqueduct, evacuation of a cerebral hemorrhage in cases of recent decline into stupor and coma, and hemicraniectomy in the case of massive stroke edema Also, thrombolytic therapy and anticoagulants are sometimes successful in reversing the progression of basilar artery thrombosis These procedures are best carried out in centers with experience in cerebrovascular intensive care If coma persists or is deep and sudden, only supportive treatment is possible Seizures Following Stroke With the exception of infarction due to cerebral venous occlusion, epileptic seizures following stroke are not a great problem As mentioned earlier and in other chapters of the book, seizures are quite infrequent as the initial manifestation of an ischemic stroke, and when they do occur in this fashion, an embolus is usually the causative mechanism.

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In the data presented by Lamy and colleagues (who were studying stroke in young patients with patent foramen ovale), when seizures occurred not at the outset but within the rst week after stroke, as they did in 2 to 4 percent of their cases, about half had another seizure, usually single, during the next several years However, the same was true for those with a rst seizure after 1 week No satisfactory study has been conducted to determine if these patients bene t from anticonvulsant therapy to prevent the second or subsequent seizures Following the practice of most other neurologists, we prescribe phenytoin or an equivalent drug only if there has been a seizure and continue it for about 18 months If the EEG continues to show focal sharp waves or other epileptic activity at that time, we continue the drug; if not, we may discontinue the medication.

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It is also clear that prophylactic anticonvulsant treatment of all stroke patients is not necessary..

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to a satis ed patient is one with clearly de ned achievable goals. Once the history is obtained, a thorough physical examination of the full face and neck is performed. Any asymmetry of the head and neck should be documented and discussed with the patient. If these are not recognized preoperatively, they may become a focus of concern and dissatisfaction postoperatively. Patient assessment begins with standard photographic representation and a complete physical examination. Standard face-lift pictures are taken in the Frankfort horizontal plane. These include full-face frontal, left and right oblique, and right and left lateral views. In addition, close-up views of the anterior neck and each ear with particular attention to the pre- and postauricular hairlines are helpful. A full set of multiview photographs (Figure 6.4) allows the surgeon and patient to (1) discuss and review the patient s expectations, (2) counsel the patient on any preexisting asymmetries, (3) relay a realistic outcome to the patient, (4) use as an intraoperative reference, and (5) evaluate postoperative outcome. Digital modi cation of the photographs can present realistic possibilities for outcomes of neck-rejuvenation

The Database Machine can be used as a real-time data warehouse in which other Oracle and non-Oracle databases can feed real-time transactions using GoldenGate. Real-time data warehouses are used by the enterprises in today s competitive landscape for performing real-time analytics and business intelligence. GoldenGate can be used in situations that require the Exadata Database Machine to feed other database systems or data warehouses that require changed data to be captured from the Database Machine and propagated to the destination systems in real time. These types of deployments allow coexistence and integration of the Database Machine with other databases that you may have deployed in the data center.

(9.28) (9.29)

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