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Overview of Intracerebral Hemorrhage

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Research Article | DOI: https://doi.org/10.31579/2578-8868/037

Overview of Intracerebral Hemorrhage

  • NS Sampath kumar 1
  • Sangamithra Gandra 1
  • Venkata Ramya Bola 1

1Professor & HOD, Department of Neurology, Narayana Medical College and Hospital, India
2Department of Neurology, Narayana Medical College and Hospital, India
3Department of Neurology, Narayana Medical College and Hospital, India
4Department of Management Information System, Narayana Medical College and Hospital, India

*Corresponding Author: NS Sampath kumar*, Sangamithra Gandra, Prasad PNS , Venkata Ramya Bola, Professor & HOD, Department of Neurology, Narayana Medical College, Chinthareddypalem, Nellore , Andhra Pradesh, India.

Citation: N S Sampath kumar ,Overview of Intracerebral Hemorrhage J Neuroscience and Neurological Surgery. 2(1);DOI:10.31579/2578-8868/037

Copyright: © 2018 Dr. N S Sampath kumar, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 17 January 2018 | Accepted: 27 January 2018 | Published: 31 January 2018

Keywords: stroke; intra cerebral hemorrhage; hypertension

Abstract

Stroke is categorized into two major subtypes i.e., ischemic and hemorrhagic and is one of the major causes of morbidity and mortality worldwide. Primary intracerebral hemorrhage (ICH), i.e. spontaneous extravasation of blood into the brain parenchyma, begins very suddenly and is a medical catastrophe. The well-known risk factors for ICH are hypertension, heavy drinking of alcohol, and anticoagulant medication. Risk factors for early death include clinical and radiological severity of the bleeding. Moreover, intraventricular bleeding, use of anticoagulants, and high blood pressure on admission also predict early death after ICH. CT brain imaging is the immediate modality for establishing diagnosis and supplemented with MR imaging depending upon aetiology. Treatment of patients with ICH includes standard supportive care, medical management and surgical intervention.

Stroke is categorized into two major subtypes i.e., ischemic and hemorrhagic and is one of the major causes of morbidity and mortality worldwide [1]. Primary intracerebral hemorrhage (ICH), is defined as bleeding that evolves within the tissue of the brain. It results from the rupture of small, penetrating vessels and is usually attributed to hypertension or amyloid angiopathy. After the onset, bleeding may continue and the hematoma grow for several hours, leading to progressive clinical deterioration of the patient’s condition [2-4]. Computed tomography (CT) soon after the onset of symptoms is crucial for the diagnosis. Case fatality is high, as 35–52% of patients die within 30 days and half of the deaths occur in the first two days [5-7]. Up to 58% of survivors have been reported to be functionally independent at 1 year [8]. The incidence of ICH varies geographically, ranging from 10 to 20/100,000 persons per year [9,10]. ICH incidence in Finland seems to be somewhat higher, 21 to 31/100,000 persons/year [11-13]. The highest incidence has been reported in Japan, 48/100,000 persons/year. The well-known risk factors for ICH are hypertension, heavy drinking of alcohol, and anticoagulant medication [14,15]. Risk factors for early death include clinical and radiological severity of the bleeding. Low Glasgow Coma Scale (GCS) score (i.e. level of consciousness) and hematoma volume appear to be the most important predictors for early death after ICH [16]. Moreover, intraventricular bleeding, use of anticoagulants, and high blood pressure on admission also predict early death after ICH [5, 8, 14 and 17-19]. Treatment of patients with ICH has turned out to be complicated in many ways.

  1. Symptoms and diagnosis of intracerebral haemorrhage

The clinical presentation of ICH usually starts with a focal neurological deficit followed by progression of symptoms over minutes to hours [20]. This symptomatic progression over hours is uncommon in patients with ischemic stroke. Another manifestation is a sudden decline in the level of consciousness. Increased blood pressure and impaired level of consciousness are common. Vomiting is more common in patients with ICH. Headache is more common with ICH than with ischemic stroke but less common than with subarachnoid hemorrhage [21]. Diagnosis is confirmed by brain imaging. Computed tomography (CT) and magnetic resonance imaging (MRI) show the presence of ICH equally well. CT has the advantage of demonstrating the intraventricular extension of the hemorrhage, while MRI shows better the underlying structures and perihematomal edema.

B. Subgroups of intracerebral hemorrhage

1. Primary intracerebral haemorrhage

The term ‘spontaneous intracerebral hematoma’ refers to non-traumatic bleeding

into the brain parenchyma [1]. ‘Primary intracerebral hemorrhage’ means a spontaneous hematoma without any secondary cause, such as vascular abnormality or brain tumour, which have been ruled out by radiological or pathological investigations [14]. Primary intracerebral hemorrhage originates from bleeding of small arteries damaged by chronic hypertension, cerebral amyloid angiopathy (CAA), or other causative factors [14,22]. Almost two thirds of primary intracerebral hematomas are related to chronic hypertension [23]. In these cases the hematoma is typically located deep, in the basal ganglia, thalamus, or brain stem [1] figure 1. ICHs related to CAA, on the other hand, are mainly lobar or subcortical hematomas [22] Figure 2

Figure 1: Left putaminal ICH in a 60-year-old female with a history of Hypertension.(Source: Report of patient admitted in Department of Neurology, Narayana Medical College & Hospital, Nellore, A.P., India).
 
Figure 2: Left parietal hematoma in a 57-year-old man without a history of Hypertension (Source: Report of patient admitted in Department of Neurology, Narayana Medical College & Hospital, Nellore, A.P., India).
 

2. Secondary intracerebral haemorrhage.

Only 12–18% of all ICH cases are classifiable as the secondary type of ICH [14]. The most important causes of secondary ICH are vascular abnormalities, which carry the risk of rebleeding. The secondary causes of ICH are represented in table 1.

Table 1: Secondary causes of ICH

Source: Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage. Stroke (1995) 26: 1764–1767.

Figure 3: A. CT scan of right-side ICH caused by AVM in a 44-year-old male. AVM is visible even in the plain CT scan (white arrow). B. 3D-DSA of the aneurysm with a small secondary aneurysm. (Source: Report of patient admitted in Department of Neurology, Narayana Medical College & Hospital, Nellore, A.P., and India).
 

C. Risk factors of primary intracerebral hemorrhage

1. Untreated and treated hypertension

Hypertension is the most prevalent risk factor for ICH [23]. It is considered a major risk factor in half of all patients presenting with ICH and in 75% of those with deep hematomas [12,24-30]. The risk of ICH increases at higher blood pressure values [31]. Untreated hypertension has been found to be a highly prevalent risk factor for hemorrhagic stroke (ICH and subarachnoid hemorrhage combined) [29, 32].

2. Diabetes

Diabetes is a well-known risk factor for ischemic stroke [33, 34]. On the other hand, it is less clear whether there is an association between diabetes and ICH [35].

3.Amyloid angiopathy and genetic factors

Cerebral amyloid angiopathy (CAA) is a major cause of lobar ICH in older patients [14, 36]. CAA is a degenerative process of arterial media, which mainly affects cortical and leptomeningeal vessels, predisposing to ICH. CAA is caused by the deposition of β-amyloid protein on the vessel wall [14]. The prevalence of CAA rises with age, being approximately 60% among those over 90 years of age [36]. The diagnosis is clinically suspected in multiple lobar bleedings with no other obvious cause of ICH in patients 55 years of age or older [37].

4. Alcohol consumption and stimulant use

The relationship between alcohol intake and increased ICH risk has been identified in many case-control studies [26&38-43]. Short-term recent moderate or heavy binge alcohol intake within 24 hours or one week seems to be a more important risk factor for ICH than long-term habitual heavy drinking [26]. Amphetamine or cocaine use can provoke ICH. This uncommon etiology is mainly seen in young adult [44]. Cigarette smoking is a well-known predictor of ischemic stroke in both men and women, [45, 46]. but its role as a risk factor for ICH is less clear.

5. Use of anticoagulants and platelet inhibitors

The risk for ICH in warfarin users has been reported to be 8 to 10-fold compared with nonusers [47, 48]. ICHs associated with oral anticoagulation account for a considerable proportion of all ICHs (6.9

F. Treatment of primary intracerebral hemorrhage

1. Conservative treatment

Conservative treatment of ICH covers all emergency and critical care procedures except operative treatment. In general, all patients with ICH should be admitted to a neurosurgical or neurological intensive care setting, because it reduces mortality [69].

2. Securing the airways

The onset of ICH is typically followed by a rapid decline of consciousness and progression of neurological symptoms. Loss of the normal reflexes to maintain an open airway develops, which increases the risk of aspiration, hypoxemia, and hypercapnia [72]. Sedatives (such as propofol) and non-depolarizing neuromuscular drugs (such as vecuronium) are used to facilitate the intubation procedure.

3. Controlling blood pressure

High admission MABP has been repeatedly reported to predict early death and poor outcome after ICH [60,62]. Blood pressure maintains the cerebral perfusion pressure (CPP), and overaggressive lowering of blood pressure may theoretically worsen cerebral perfusion in cases with high intracranial pressure (CPP = MABPICP). The recommendations of the European Stroke Initiative 2006 [15] and the American Stroke Association 2007 [73] for the management of high blood pressure are presented in Table 3.

The recommended medication for hypertension consists of intravenous 10 to 80 mg boluses of labetalol at every 10 minutes [74].

Table 3: Recommendations given by the American Heart Association (AHA) and the European Stroke Initiative (EUSI) for the treatment of acute high blood pressure in patients with IC
 

Source: The recommendations of the European Stroke Initiative 2006 (Steiner et al. 2006b) and the American Stroke Association 2007 (Broderick et al. 2007) for the management of high blood pressure.

4. Management of increased intracranial pressure

Emergency management of elevated intracranial pressure (ICP) includes head elevation, use of mannitol, and hyperventilation even before the installation of any ICP measurement devices. The management also includes sedation, phenobarbital therapy, hypothermia, and fluid infusion according to the cerebral perfusion pressure (CPP) guided therapy [50, 75-77]. Neurosurgical methods for lowering ICP include placement of an external ventricular catheter and decompressive craniectomy [78].  

5. Reversal of anticoagulation

Anticoagulant treatment preceding the onset of ICH is related to high mortality and poor functional outcome compared to ICH without preceding anticoagulation [25,49,79]. Anticoagulation should be reversed immediately to prevent further deterioration, and warfarin users should have their International Normalized ratio (INR) value lowered below 1.4 immediately after the diagnosis of ICH [80]. This is done by using either fresh frozen plasma or prothrombin complex concentrate together with vitamin K. If the patient has used heparin or low molecular weight heparins (LMWH) before the onset of ICH, the effect of the medication should be reversed with protamine sulphate [81].

Conclusion

ICH is most commonly caused by hypertension, arteriovenous malformations, or head trauma. Intracerebral hemorrhage results in sudden, severe symptoms like headache, loss of consciousness, vomiting but headache may be absent (particularly in the elderly), and small hemorrhages may mimic ischemic stroke. CT brain imaging is the immediate modality for establishing diagnosis and supplemented with MR imaging depending upon aetiology. Treatment of patients with ICH includes standard supportive care, medical management and surgical intervention.

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Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

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Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

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Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

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Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

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Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

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The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

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Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

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Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

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Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

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Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

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Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

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S Munshi

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Tania Munoz

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin