Öz
Objective: Intracerebral hematomas ICH comprise one-fifth of all strokes and is associated with high mortality and morbidity rates. We aimed to analyze the clinical-radiological features, surgical treatment indications and results of spontaneous ICH in a large clinical series from a single institution.Materials and Methods: All patients who are older than 18 years of age and underwent surgery for spontaneous ICH between January 2006 and December 2017 were included. Patient charts, radiological images, operation notes and follow-up results were retrospectively evaluated. Data about age, sex, risk factors, neurological status at presentation, location and size of the hematoma, surgical technique, postoperative neurological outcomes, reoperation and follow-up results were collected.Findings: A total of 88 patients 30 female 34.1% , 58 male 65.9% were operated for spontaneous ICH. Mean age was 59.3±20.1 years range: 18–89, median: 62 . The main symptoms and signs were loss of consciousness, nausea-vomiting, severe headache, agitation, seizure and motor weakness hemiplegia . Patients were admitted at varying times from 20 minutes to 5 hours following the symptom onset. Decompressive hemicraniectomy + hematoma aspiration was performed in 74 84.1% patients whereas 14 patients underwent craniotomy + hematoma aspiration. External ventricular drainage was required in 22 25% of 58 patients 65.9% who had an intraventricular bleed. Recurrent bleeding or increased hematoma size was detected in 5 5.7% of 37 42% patients using antiaggregant/anticoagulant agents. Forty-seven 53.4% patients died within the first 30 days after bleeding. The 30-day mortality rate was 88% in patients with GCS ≤8 and blood volume >70 cm3.Conclusion: ICH is more common in elderly, hypertensive patients with a history of antiaggregant/anticoagulant use. The older age, multiple comorbid diseases, large hematoma volume, low GCS at presentation are associated with poor prognosis. An early and effective surgical treatment can be life-saving especially in patients who are young, have no comorbid disease and a relatively good neurological state or with a sudden worsening
Anahtar Kelimeler
intracerebral hematoma hemorrhagic stroke surgery decompression craniectomy
Kaynakça
- 1. Yan F, Yi Z, Hua Y, Shen Y, Li M, Ding Y, et al. Predictors of mortality and recurrent stroke within five years of intracerebral hemorrhage. Neurol Res 2018;40:466–72. [CrossRef]
- 2. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the global burden of disease study 2010. Lancet 2013;381:1987–2015. [CrossRef]
- 3. Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus 2013;34:E5. [CrossRef]
- 4. Mendelow AD, Gregson BA, Mitchell PM, Murray GD, Rowan EN, Gholkar AR, the STICH II Investigators. Surgical trial in lobar intracerebral haemorrhage (STICH II) protocol. Trials 2011;12:124. [CrossRef]
- 5. Bhaskar MK, Kumar R, Ojha B, Singh SK, Verma N, Verma R, et al. A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage. Neurol India 2017;65:752–8. [CrossRef]
- 6. Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2015;46:2032–60. [CrossRef]
- 7. Rasras S, Safari H, Zeinali M, Jahangiri M. Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage. Clin Neurol Neurosurg 2018;174:1–6. [CrossRef]
- 8. Counsell C, Boonyakarnkul S, Dennis M, Sandercock P, Bamford J, Burn J, Warlow C. Primary intracerebral haemorrhage in the Oxfordshire community stroke project 2 prognosis. Cerebrovasc Dis 1995;5:26–34. [CrossRef]
- 9. Luh HT, Huang APH, Yang SH, Chen CM, Cho DY, Chen CC, et al. Local hemostatic matrix for endoscope-assisted removal of intracerebral hemorrhage is safe and effective. J Formos Med Assoc 2018;117:63– 70. [CrossRef]
- 10. Brouwers HB, Goldstein JN. Therapeutic strategies in acute intracerebral hemorrhage. Neurotherapeutics 2012;9:87–98. [CrossRef]
- 11. Hanggi D, Steiger HJ. Spontaneous intracerebral haemorrhage in adults: a literature overview. Acta Neurochir (Wien) 2008;150:371–9, discussion 9. [CrossRef]
- 12. Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol 2012;11:101–18. [CrossRef]
- 13. Lo Presti MA, Bruce SS, Camacho E, Kunchala S, Dubois BG, Bruce E, et al. Hematoma volume as the major determinant of outcomes after intracerebral hemorrhage. J Neurol Sci 2014;345:3–7. [CrossRef]
- 14. Zheng JS, Yang F, Xu QS, Yu JB, Tang LL. Treatment of hypertensive intracerebral hemorrhage through keyhole Transsylvian approach. J Craniofac Surg 2010;21:1210–2. [CrossRef]
- 15. Kirkman MA, Smith M. Supratentorial intracerebral hemorrhage: a review of the underlying pathophysiology and its relevance for multimodality neuromonitoring in neurointensive care. J Neurosurg Anesthesiol 2013;25:228–39. [CrossRef]
- 16. Fernandes HM, Mendelow AD. Spontaneous intracerebral haemorrhage: a surgical dilemma. Br J Neurosurg 1999;13:389–94. [CrossRef]
- 17. Gregson BA, Mendelow AD, for STICH Investigators. International variations in surgical practice for spontaneous intracerebral haemorrhage. Stroke 2003;34:2593–8. [CrossRef]
- 18. Maira G, Anile C, Colosimo C, Rossi GF. Surgical treatment of primary supratentorial intracerebral hemorrhage in stuporous and comatose patients. Neurol Res 2002;24:54–60. [CrossRef]
- 19. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365:387–397. [CrossRef]
- 20. Miller CM, Vespa P, Saver JL, Kidwell CS, Carmichael ST, Alger J, et al. Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage. Surg Neurol 2008;69:441–6. [CrossRef]
- 21. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kourne T, Kaste M, Troupp H. The treatment of spontaneous intracerebral hemorrhage: A prospective randomized trial of surgical and conservative treatment. J Neurosurg 1989;70:755–8. [CrossRef]
- 22. Ramnarayan R, Anto D, Anilkumar TV, Nayar R. Decompressive hemicraniectomy in large putaminal hematomas: an Indian experience. J Stroke Cerebrovasc Dis 2009;18:1–10. [CrossRef]
- 23. Fung C, Murek M, Z’Graggen WJ, Krähenbühl AK, Gautschi OP, Schucht P, et al. Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke 2012;43:3207–11. [CrossRef]
- 24. Heuts SG, Bruce SS, Zacharia BE, Hickman ZL, Kellner CP, Sussman ES, et al. Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis. Neurosurg Focus 2013;34:E4. [CrossRef]
- 25. Esquenazi Y, Savitz S, Khoury RE, McIntosh MA, Grotta JC, Tandon N. Decompressive hemicraniectomy with or without clot evacuation forlarge spontaneous supratentorial intracerebral hemorrhages. Clin Neurol Neurosurg 2015;128:117–22. [CrossRef]
- 26. De Bonis P, Pompucci A, Mangiola A, Rigante L, Anile C. Posttraumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor. J Neurotrauma 2010;27:1965–70. [CrossRef]
- 27. Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, et al. Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir (Wien) 2009;151:21–30. [CrossRef]
- 28. Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, Zhan RY. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150:1241–8. [CrossRef]
- 29. Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013;27:979–91. [CrossRef]
- 30. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 2006;104:469–79. [CrossRef]
- 31. Kontopoulos V, Foroglou N, Patsalas J, Magras J, Foroglou G, Yiannakou-Pephtoulidou M, et al. Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered? Acta Neurochir (Wien) 2002;144:791–6. [CrossRef ]
- 32. Schaller B, Graf R, Sanada Y, Rosner G, Wienhard K, Heiss WD. Hemodynamic and metabolic effects of decompressive hemicraniectomy in normal brain. An experimental PET study in cats. Brain Res 2003;982:31–7. [CrossRef]
- 33. Siddique MS, Fernandes HM, Wooldridge TD, Fenwick JD, Slomka P, Mendelow AD. Reversible ischemia around intracerebral hemorrhage: a single-photon emission computerized tomography study. J Neurosurg 2002;96:736–41. [CrossRef]
- 34. Zhou X, Chen J, Li Q, Ren G, Yao G, Liu M, et al. Minimally invasive surgery for spontaneous supratentorial intracerebral hemorrhage: a meta-analysis of randomized controlled trials. Stroke 2012;43:2923– 30. [CrossRef]
- 35. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-touse predictor of 30-day mortality. Stroke 1993;24:987–93. [CrossRef]
- 36. Elijovich L, Patel PV, Hemphill J. Intracerebral hemorrhage. Semin Neurol 2008;28:657–67. [CrossRef]
- 37. Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC. Surgical treatment for intracerebral hemorrhage (STICH): A singlecenter, randomized clinical trial. Neurology 1998;51:1359–63. [CrossRef]
- 38. Fernandes HM, Gregson B, Siddique S, Mendelow AD. Surgery in intracerebral hemorrhage: the uncertainty continues. Stroke 2000;31:2511–6. [CrossRef]
- 39. Mitchell P, Gregson BA, Vindlacheruvu RR, Mendelow AD. Surgical options inICH including decompressive craniectomy. J Neurol Sci 2007;261:89–98. [CrossRef]
- 40. Gregson BA, Broderick JP, Auer LM, Batjer H, Chen XC, Juvela S, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke 2012;43:1496–504. [CrossRef]
Öz
Amaç: Bu çalışmanın amacı tüm inmelerin yaklaşık beşte birini oluşturan ve yüksek mortalite ve morbidite oranlarına sahip intraserebral hematomların İSH klinik-radyolojik özellikleri, cerrahi tedavi endikasyonları ve sonuçlarını geniş bir klinik seriden elde edilen tecrübeler ışığında analiz etmektir.Gereç ve Yöntem: Çalışmaya Ocak 2006 – Aralık 2017 tarihleri arasında, spontan İSH nedeniyle kliniğimizde ameliyat edilen 18 yaş üstü tüm hastalar dahil edildi. Hastaların epikriz kayıtları, radyolojik görüntüleri, ameliyat notları ve takip sonuçları retrospektif olarak incelendi. Yaş, cinsiyet, risk faktörü varlığı, başvuru anındaki nörolojik durum, hematomun lokalizasyonu ve hacmi, radyolojik özellikler, cerrahi teknik, postoperatif nörolojik sonuçlar, re-operasyon ve takip sonuçlarını içeren veriler toplandı.Bulgular: Spontan İSH nedeniyle toplam 88 hasta 30 kadın %34,1 , 58 erkek %65,9 opere edildi. Tanı anındaki yaş ortalaması 59,3±20,1 yıl aralık: 18–97, ortanca: 62 olarak hesaplandı. Başlıca başvuru semptom ve bulguları bilinç kaybı, bulantı-kusma, şiddetli baş ağrısı, ajitasyon, nöbet ve kuvvet kaybı hemipleji idi. Hastalar semptomların ortaya çıkışını takiben 20 dakika ile 5 saat arasında değişen sürelerde acile başvurdu. 74 hastaya %84,1 dekompresif hemikraniyektomi + hematom aspirasyonu, 14 hastaya %15,9 kraniyotomi + hematom aspirasyonu uygulandı. Ventriküle açılmış kanaması olan 58 hastanın %65,9 22’sinde %25 izlemde gelişen hidrosefali nedeniyle eksternal ventriküler drenaj EVD ihtiyacı oldu. Antiagregan/antikoagülan kullanımı olan 37 %42 hastanı 5’inde %5,7 tekrarlayan kanama veya hematom boyutunda artış gözlendi. Hastaların 47’si %53,4 kanamadan sonraki ilk 30 gün içinde hayatını kaybetti. GKS’si 8 ve daha düşük, kan hacmi ise 70 cm3’ün üzerinde olan hastalarda ise bu dönemde ölüm oranı %88 olarak bulundu.Sonuç: Antiagregan/antikoagülan kullanım öyküsü bulunan, yaşlı, hipertansif hastalarda daha yaygın görülen İSH mortalite ve morbiditesi oldukça yüksek bir hastalıktır. İleri yaş, çoklu yandaş hastalık varlığı, büyük hematom hacmi, başvuru anındaki düşük Glasgow koma skalası kötü prognoz ile ilişkilidir. Erken ve etkili cerrahi tedavi özellikle genç, yandaş hastalığı olmayan, nörolojik durumu nisbeten iyi veya ani kötüleşen hastalarda hayat kurtarıcı olabilmektedir
Anahtar Kelimeler
Intraserebral hematom hemorajik inme cerrahi dekompresyon kraniyektomi
Kaynakça
- 1. Yan F, Yi Z, Hua Y, Shen Y, Li M, Ding Y, et al. Predictors of mortality and recurrent stroke within five years of intracerebral hemorrhage. Neurol Res 2018;40:466–72. [CrossRef]
- 2. Yang G, Wang Y, Zeng Y, Gao GF, Liang X, Zhou M, et al. Rapid health transition in China, 1990–2010: findings from the global burden of disease study 2010. Lancet 2013;381:1987–2015. [CrossRef]
- 3. Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus 2013;34:E5. [CrossRef]
- 4. Mendelow AD, Gregson BA, Mitchell PM, Murray GD, Rowan EN, Gholkar AR, the STICH II Investigators. Surgical trial in lobar intracerebral haemorrhage (STICH II) protocol. Trials 2011;12:124. [CrossRef]
- 5. Bhaskar MK, Kumar R, Ojha B, Singh SK, Verma N, Verma R, et al. A randomized controlled study of operative versus nonoperative treatment for large spontaneous supratentorial intracerebral hemorrhage. Neurol India 2017;65:752–8. [CrossRef]
- 6. Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2015;46:2032–60. [CrossRef]
- 7. Rasras S, Safari H, Zeinali M, Jahangiri M. Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage. Clin Neurol Neurosurg 2018;174:1–6. [CrossRef]
- 8. Counsell C, Boonyakarnkul S, Dennis M, Sandercock P, Bamford J, Burn J, Warlow C. Primary intracerebral haemorrhage in the Oxfordshire community stroke project 2 prognosis. Cerebrovasc Dis 1995;5:26–34. [CrossRef]
- 9. Luh HT, Huang APH, Yang SH, Chen CM, Cho DY, Chen CC, et al. Local hemostatic matrix for endoscope-assisted removal of intracerebral hemorrhage is safe and effective. J Formos Med Assoc 2018;117:63– 70. [CrossRef]
- 10. Brouwers HB, Goldstein JN. Therapeutic strategies in acute intracerebral hemorrhage. Neurotherapeutics 2012;9:87–98. [CrossRef]
- 11. Hanggi D, Steiger HJ. Spontaneous intracerebral haemorrhage in adults: a literature overview. Acta Neurochir (Wien) 2008;150:371–9, discussion 9. [CrossRef]
- 12. Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol 2012;11:101–18. [CrossRef]
- 13. Lo Presti MA, Bruce SS, Camacho E, Kunchala S, Dubois BG, Bruce E, et al. Hematoma volume as the major determinant of outcomes after intracerebral hemorrhage. J Neurol Sci 2014;345:3–7. [CrossRef]
- 14. Zheng JS, Yang F, Xu QS, Yu JB, Tang LL. Treatment of hypertensive intracerebral hemorrhage through keyhole Transsylvian approach. J Craniofac Surg 2010;21:1210–2. [CrossRef]
- 15. Kirkman MA, Smith M. Supratentorial intracerebral hemorrhage: a review of the underlying pathophysiology and its relevance for multimodality neuromonitoring in neurointensive care. J Neurosurg Anesthesiol 2013;25:228–39. [CrossRef]
- 16. Fernandes HM, Mendelow AD. Spontaneous intracerebral haemorrhage: a surgical dilemma. Br J Neurosurg 1999;13:389–94. [CrossRef]
- 17. Gregson BA, Mendelow AD, for STICH Investigators. International variations in surgical practice for spontaneous intracerebral haemorrhage. Stroke 2003;34:2593–8. [CrossRef]
- 18. Maira G, Anile C, Colosimo C, Rossi GF. Surgical treatment of primary supratentorial intracerebral hemorrhage in stuporous and comatose patients. Neurol Res 2002;24:54–60. [CrossRef]
- 19. Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365:387–397. [CrossRef]
- 20. Miller CM, Vespa P, Saver JL, Kidwell CS, Carmichael ST, Alger J, et al. Image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage. Surg Neurol 2008;69:441–6. [CrossRef]
- 21. Juvela S, Heiskanen O, Poranen A, Valtonen S, Kourne T, Kaste M, Troupp H. The treatment of spontaneous intracerebral hemorrhage: A prospective randomized trial of surgical and conservative treatment. J Neurosurg 1989;70:755–8. [CrossRef]
- 22. Ramnarayan R, Anto D, Anilkumar TV, Nayar R. Decompressive hemicraniectomy in large putaminal hematomas: an Indian experience. J Stroke Cerebrovasc Dis 2009;18:1–10. [CrossRef]
- 23. Fung C, Murek M, Z’Graggen WJ, Krähenbühl AK, Gautschi OP, Schucht P, et al. Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke 2012;43:3207–11. [CrossRef]
- 24. Heuts SG, Bruce SS, Zacharia BE, Hickman ZL, Kellner CP, Sussman ES, et al. Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis. Neurosurg Focus 2013;34:E4. [CrossRef]
- 25. Esquenazi Y, Savitz S, Khoury RE, McIntosh MA, Grotta JC, Tandon N. Decompressive hemicraniectomy with or without clot evacuation forlarge spontaneous supratentorial intracerebral hemorrhages. Clin Neurol Neurosurg 2015;128:117–22. [CrossRef]
- 26. De Bonis P, Pompucci A, Mangiola A, Rigante L, Anile C. Posttraumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor. J Neurotrauma 2010;27:1965–70. [CrossRef]
- 27. Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, et al. Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir (Wien) 2009;151:21–30. [CrossRef]
- 28. Yang XF, Wen L, Shen F, Li G, Lou R, Liu WG, Zhan RY. Surgical complications secondary to decompressive craniectomy in patients with a head injury: a series of 108 consecutive cases. Acta Neurochir (Wien) 2008;150:1241–8. [CrossRef]
- 29. Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013;27:979–91. [CrossRef]
- 30. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 2006;104:469–79. [CrossRef]
- 31. Kontopoulos V, Foroglou N, Patsalas J, Magras J, Foroglou G, Yiannakou-Pephtoulidou M, et al. Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered? Acta Neurochir (Wien) 2002;144:791–6. [CrossRef ]
- 32. Schaller B, Graf R, Sanada Y, Rosner G, Wienhard K, Heiss WD. Hemodynamic and metabolic effects of decompressive hemicraniectomy in normal brain. An experimental PET study in cats. Brain Res 2003;982:31–7. [CrossRef]
- 33. Siddique MS, Fernandes HM, Wooldridge TD, Fenwick JD, Slomka P, Mendelow AD. Reversible ischemia around intracerebral hemorrhage: a single-photon emission computerized tomography study. J Neurosurg 2002;96:736–41. [CrossRef]
- 34. Zhou X, Chen J, Li Q, Ren G, Yao G, Liu M, et al. Minimally invasive surgery for spontaneous supratentorial intracerebral hemorrhage: a meta-analysis of randomized controlled trials. Stroke 2012;43:2923– 30. [CrossRef]
- 35. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-touse predictor of 30-day mortality. Stroke 1993;24:987–93. [CrossRef]
- 36. Elijovich L, Patel PV, Hemphill J. Intracerebral hemorrhage. Semin Neurol 2008;28:657–67. [CrossRef]
- 37. Morgenstern LB, Frankowski RF, Shedden P, Pasteur W, Grotta JC. Surgical treatment for intracerebral hemorrhage (STICH): A singlecenter, randomized clinical trial. Neurology 1998;51:1359–63. [CrossRef]
- 38. Fernandes HM, Gregson B, Siddique S, Mendelow AD. Surgery in intracerebral hemorrhage: the uncertainty continues. Stroke 2000;31:2511–6. [CrossRef]
- 39. Mitchell P, Gregson BA, Vindlacheruvu RR, Mendelow AD. Surgical options inICH including decompressive craniectomy. J Neurol Sci 2007;261:89–98. [CrossRef]
- 40. Gregson BA, Broderick JP, Auer LM, Batjer H, Chen XC, Juvela S, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke 2012;43:1496–504. [CrossRef]
Ayrıntılar
| Birincil Dil | Türkçe |
|---|---|
| Bölüm | Research Article |
| Yazarlar | |
| Yayımlanma Tarihi | 1 Eylül 2020 |
| Yayımlandığı Sayı | Yıl 2020Sayı: 3 |