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Iryaningrum MR, Ivan I, Budiman F, Tamio E. Electrocardiographic Manifestation in Thyrotoxic Periodic Paralysis. Cureus 2022; 14:e21619. [PMID: 35233304 PMCID: PMC8881231 DOI: 10.7759/cureus.21619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/05/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is an unusual complication of hyperthyroidism that may cause diagnostic difficulties due to its clinical feature that may be similar to other diseases. However, TPP can be detected early based on the weakness presentation, which generally affects the lower extremity with proximal muscle involvement, and, additionally, the ECG findings presenting hypokalemia characteristics. This case illustrates a young Indonesian male presenting in the emergency department with paralysis and typical ECG findings suggesting TPP. Early identification of TPP is necessary for executing proper treatment and reducing complications.
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Hypokalemic Periodic Paralysis as the First Manifestation of Thyrotropin-Secreting Pituitary Adenoma. Case Rep Endocrinol 2019; 2019:5913194. [PMID: 31737378 PMCID: PMC6815973 DOI: 10.1155/2019/5913194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/10/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Thyrotoxic periodic paralysis is an unusual neurological manifestation of thyrotoxicosis, and even rarer when it occurs in thyrotropin-secreting pituitary adenoma, only 6 cases having been previously reported. We describe a case of pituitary microadenoma with clinical syndromes of thyrotoxicosis complicated with hypokalemic periodic paralysis. Clinical manifestations and proposed management are discussed.
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Davoudi Z, Chouhdari A, Rezaei O, Guive G. Pituitary macroadenoma resulting from primary hypothyroidism; a 16-year-old girl. CASPIAN JOURNAL OF INTERNAL MEDICINE 2019; 10:347-350. [PMID: 31559000 PMCID: PMC6729158 DOI: 10.22088/cjim.10.3.347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Primary hypothyroidism is a common medical condition. It can lead to pituitary adenoma which is usually asymptomatic, but it can also lead to symptomatic macroadenomas which are hard to diagnose due to different clinical presentations. Case presentation: A 16-year-old girl presented for endocrinology consultation prior to neurosurgical operation. She had galactorrhea which was accompanied by vertigo & low grade blurred vision without a headache and was diagnosed with pituitary macroadenoma and was planned for a surgery. She had TSH level of more than 100 mU/L, free thyroxine of 1.9 pmol/L. Her thyroid peroxidase (TPO) antibody level was 13.3 IU/mL, insulin growth factor-1 392 µ/l and serum prolactin level 42 ng/ml. During physical exam and with the laboratory findings, we suspected for a primary hypothyroidism as the leading cause of pituitary macroadenoma. As the result, we cancel the surgery and start levothyroxine therapy 100µg daily for her. In the follow-up it revealed that our diagnosis was correct and she went into remission with pituitary gland shrinking and decreasing TSH and prolactin levels. Conclusion: It is important to understand the different presentation of primary hypothyroidism to decrease the unnecessary risk of maltreatment in patients.
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Affiliation(s)
- Zahra Davoudi
- Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arezoo Chouhdari
- Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omidvar Rezaei
- Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Guive Guive
- Skull Base Research Center, Loghman Hakim Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Neurosurgery, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Garla VV, Gunturu M, Kovvuru KR, Salim SA. Thyrotoxic periodic paralysis: case report and review of the literature. Electron Physician 2018; 10:7174-7179. [PMID: 30214699 PMCID: PMC6122872 DOI: 10.19082/7174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction Thyrotoxic periodic paralysis (TPP) is a rare and potentially lethal complication of hyperthyroidism. It is characterized by sudden onset paralysis associated with hypokalemia. Management includes prompt normalization of potassium, which results in resolution of the paralysis. Definitive treatment of hyperthyroidism resolves TPP completely. Case presentation A 23-year-old African American male patient presented to the emergency room at the University of Mississippi Medical Center, USA in November 2016 with sudden onset quadriplegia. He also endorsed a history of weight loss, palpitations, heat intolerance and tremors. The patient reported similar episodes of quadriplegia in the past, which were associated with hypokalemia and resolved with normalization of potassium levels. Physical examination was significant for exophthalmos, smooth goiter with bruit consistent with the diagnosis of Graves’ disease. Laboratory assessment showed severe hypokalemia, hypomagnesemia, suppressed thyroid stimulating hormone (TSH) and high free thyroxine (T4). Urine potassium creatinine ratio was less than one, indicating transcellular shift as the cause of hypokalemia. After normalization of potassium and magnesium, the paralysis resolved in 12 hours. He was started on methimazole. On follow up, the patient was clinically and biochemically euthyroid with no further episodes of paralysis. Take-away lesson TPP is a rare and reversible cause of paralysis. Physicians need to be aware of the diagnostic and treatment modalities as delayed recognition in treatment could result in potential harm or unnecessary interventions.
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Affiliation(s)
- Vishnu Vardhan Garla
- MD., Assistant Professor, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA
| | - Manasa Gunturu
- MD., Resident Physician, Department of Neurology, University of Mississippi Medical Center, Jackson, USA
| | - Karthik Reddy Kovvuru
- MD., Clinical Fellow, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA
| | - Sohail Abdul Salim
- MD., Assistant Professor, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, USA
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Falhammar H, Thorén M, Calissendorff J. Thyrotoxic periodic paralysis: clinical and molecular aspects. Endocrine 2013; 43:274-84. [PMID: 22918841 DOI: 10.1007/s12020-012-9777-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/13/2012] [Indexed: 10/28/2022]
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that most often affects young East Asian males but increasingly also in other ethnic groups. The typical presentation is acute attacks varying from mild weakness to total paralysis starting at night or in the early morning a few hours after a heavy meal, alcohol abuse or strenuous exercise with complete recovery within 72 h. Signs and symptoms of hyperthyroidism may not be obvious. The hallmark is hypokalemia from increased cellular sodium/potassium-ATPase pump activity with transport of potassium from the extracellular to the intracellular space in combination with reduced potassium output. Recently, KCNJ18 gene mutations which alter the function of an inwardly rectifying potassium channel named Kir2.6 have been detected in 0-33 % of cases. Hence, the pathophysiology in TPP includes a genetic predisposition, thyrotoxicosis and environmental influences and the relative impact from each of these factors may vary. The initial treatment, which is potassium supplementation, should be given with caution due to a high risk of hyperkalemia. Propranolol is an alternative first-line therapeutic option based on the assumption that hyperadrenergic activity is involved in the pathogenesis. If thyroid function tests are unobtainable in the acute situation the diagnosis is supported by the findings of hypokalemia, low spot urine potassium excretion, hypophosphatemia with hypophosphaturia, high spot urine calcium/phosphate ratio, and electrocardiographic abnormalities as tachycardia, atrial fibrillation, high QRS voltage, and atrioventricular block. Definitive treatment is cure of the hyperthyroidism. The underlying mechanisms of TPP remain, however, incompletely understood awaiting further studies.
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Affiliation(s)
- Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, D2:04, Karolinska University Hospital, 171 76, Stockholm, Sweden.
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Ghosh S, Sahoo R, Rao S, Rath D. Pituitary macroadenoma: a rare cause of thyrotoxic hypokalaemic periodic paralysis. BMJ Case Rep 2013; 2013:bcr-2012-008411. [PMID: 23391961 DOI: 10.1136/bcr-2012-008411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thyrotoxic hypokalaemic periodic palsy (THPP) is a well-recognised but under-diagnosed complication of hyperthyroidism and is commonly seen in Asian males. Patients usually present fully conscious with acute onset of severe motor weakness. Baseline investigation reveals severe hypokalaemia due to Na(+)/K(+) ATPase overactivity causing a massive influx of intracellular potassium ions. The most common cause of THPP identified in the medical literature is Graves' disease. We report an interesting and unusual case of THPP due to previously undiagnosed hyperthyroidism secondary to a pituitary macroadenoma. The patient was consequently found to have a tumour secreting gonadotropin and thyrotropin.
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Affiliation(s)
- Soumik Ghosh
- Department of Medicine, PGIMER & Dr Ram Manohar Lohia Hospital, New Delhi, India.
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A Rare Case of Thyrotoxic Periodic Paralysis Presenting to the Medical Examiner. Am J Forensic Med Pathol 2011; 32:232-5. [DOI: 10.1097/paf.0b013e318219ca5b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pothiwala P, Levine SN. Analytic review: thyrotoxic periodic paralysis: a review. J Intensive Care Med 2010; 25:71-7. [PMID: 20089526 DOI: 10.1177/0885066609358849] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Thyrotoxic periodic paralysis (TPP) is an unusual complication of hyperthyroidism that frequently presents in a dramatic fashion, necessitating treatment in an emergency department or admission to an intensive care unit. Thyrotoxic periodic paralysis is characterized by transient, recurrent episodes of flaccid muscle paralysis affecting proximal more severely than distal muscles. Thyrotoxic periodic paralysis is most commonly a complication of Graves' disease in Asian males, although in recent decades, an increasing number of patients from all racial and ethnic backgrounds have been reported. Thyrotoxic periodic paralysis has a higher predilection for men than women despite the fact that thyroid disease is more frequently diagnosed in women. The presence of both hypokalemia and elevated levels of triiodothyronine (T3) and thyroxine (T4) are important diagnostic features during the acute episode. Treatment of TPP involves 2 steps, immediate action to reverse the paralysis followed by measures to prevent future attacks by restoration of a euthyroid state. Although the mainstay of treating an acute attack of TPP is correction of hypokalemia to avoid fatal cardiac arrhythmias and reverse muscle weakness, it must be appreciated by treating physicians that patients with TPP do not have a total body deficiency of potassium. Close attention must be given to potassium replacement as overly aggressive treatment can result in hyperkalemia. Correction of hypokalemia and the underlying thyrotoxic state usually results in amelioration of the acute attack. This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnosis, and treatment of TPP.
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Affiliation(s)
- Pooja Pothiwala
- Department of Medicine, Section of Endocrinology and Metabolism, Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA.
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Cesur M, Bayram F, Temel MA, Ozkaya M, Kocer A, Ertorer ME, Koc F, Kaya A, Gullu S. Thyrotoxic hypokalaemic periodic paralysis in a Turkish population: three new case reports and analysis of the case series. Clin Endocrinol (Oxf) 2008; 68:143-52. [PMID: 17897330 DOI: 10.1111/j.1365-2265.2007.03014.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Thyrotoxic hypokalaemic periodic paralysis (THPP) is an uncommon condition with intermittent episodes of muscle weakness and occasionally severe paralysis. THPP is a common complication of hyperthyroidism in Asian populations, and has also been reported in other ethnic groups including Caucasians. This study aimed to conduct an analysis of THPP in a Turkish population, and is to our knowledge the first analysis of a homogeneous Caucasian group. SUBJECTS Forty cases with THPP were identified in the Turkish population. Three out of the 40 were new cases and were assigned as index cases. Two cases were not included in the analysis because of lack of data. RESULTS THPP was diagnosed in 10 cases during the first attack and was observed to have a significant shorter complete recovery time statistically in this group (P < 0.01). The majority of cases were hypokalaemic, while there were two normokalaemic cases. Classification of the cases according to their potassium (K) levels revealed that the group with K levels < 2.5 mEq/l had a statistically longer amelioration time than the group with K levels > or = 2.5 mEq/l. When the cases were classified according to intravenous or oral application of K, the mean amelioration time was 6.8 +/- 3.6 h for the intravenous group and 13.1 +/- 7.6 for the oral group. Mean complete recovery times of the groups were 29.4 +/- 16.2 h and 52.8 +/- 18.0 h, respectively. The intravenous group had a shorter amelioration time and complete recovery time, and both were statistically significant (P < 0.05 for each). CONCLUSIONS THPP may be seen among Caucasians. Diagnosing THPP during the first attack might decrease the recovery time. The level of hypokalaemia seems to affect the recovery time and initial low K levels may lead to more deterioration in a patient's health compared with mild or near-normal levels. Intravenous, rather than oral, application of K may be advantageous for shortening both the amelioration and complete recovery times.
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Affiliation(s)
- Mustafa Cesur
- Ufuk University, Faculty of Medicine, Department of Endocrinology and Metabolic Diseases, Ankara, Turkey.
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Abstract
Toxic thyroid adenoma presenting as hypokalemic periodic paralysis is extraordinarily rare. We describe a 26-year-old Japanese man who suffered from acute and painful muscle weakness of extremity in the morning. Physical examination showed a left anterior neck mass and laboratory tests revealed hypokalemia during his paralysis, and thyrotoxicosis. Neck sonogram showed a solitary nodule in the left lobe of the thyroid. Thyroid scintigraphy revealed a hot nodule of the tumor region with suppressed uptake in the other thyroid area. The tumor was surgically removed and his paralytic attack ceased. No somatic mutation of TSH receptor was found in his thyroid adenoma and no known genetic mutations of ionic channel genes, such as calcium (CACN1S), sodium (SCN4A) and potassium (KCNE3), were found. Although thyrotoxic periodic paralysis is usually accompanied with Graves' disease, thyrotoxicosis of other conditions including Plummer's disease should be considered.
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Affiliation(s)
- Tetsuya Tagami
- Clinical Research Institute, Division of Endocrinology and Metabolism, Kyoto Medical Center, National Hospital Organization, Japan
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Pompeo A, Nepa A, Maddestra M, Feliziani V, Genovesi N. Thyrotoxic hypokalemic periodic paralysis: An overlooked pathology in western countries. Eur J Intern Med 2007; 18:380-90. [PMID: 17693226 DOI: 10.1016/j.ejim.2007.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Revised: 03/12/2007] [Accepted: 03/16/2007] [Indexed: 11/26/2022]
Abstract
Thyrotoxic hypokalemic periodic paralysis (THPP) is a complication of hyperthyroidism that is mostly diagnosed in Asian populations; consequently, it can be difficult to recognize in western populations. THPP represents an endocrine emergency that can result in respiratory insufficiency, cardiac arrhythmias, and death. Its differential diagnosis from the other more common forms of hypokalemic paralysis is important to avoid inappropriate therapy. Here, we discuss the main pathogenetic hypotheses, clinical features, and therapies of this disease. We also report an example of THPP management in our primary care unit.
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Affiliation(s)
- Arsenio Pompeo
- Division of Internal Medicine, "Floraspe Renzetti" Hospital, A.S.L. 103 Lanciano-Vasto, via del Mare, 1. 66034 Lanciano (Ch), Italy
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Nemergut EC, Dumont AS, Barry UT, Laws ER. Perioperative management of patients undergoing transsphenoidal pituitary surgery. Anesth Analg 2005; 101:1170-1181. [PMID: 16192540 DOI: 10.1213/01.ane.0000166976.61650.ae] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pituitary adenomas often present with the symptoms of hormonal hypersecretion, and although medical therapy is available for most hyperfunctioning states, it is not curative. As a result, transsphenoidal pituitary surgery has become a commonly performed neurosurgical procedure with unique challenges for the anesthesiologist due to the distinct medical comorbidities associated with various adenomas. Any type of pituitary tumor may also produce hypopituitarism and local mass effects secondary to the expanding intrasellar mass. Here we review the perioperative concerns surrounding surgery to remove adenomas and decompress the sellar space. Special attention is given to Cushing's disease (hypercortisolism secondary to an adrenocorticotropic hormone-secreting adenoma), acromegaly (secondary to a growth hormone-secreting adenoma), and hyperthyroidism in the setting of thyrotropic adenomas. Operative risks, including bleeding, diabetes insipidus, the syndrome of inappropriate antidiuretic hormone secretion, and hypopituitarism, are addressed in detail. Understanding preoperative assessment, intraoperative management, potential complications, their management, and strategies for avoidance are fundamental to successful perioperative patient care and avoidance of morbidity and mortality.
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Affiliation(s)
- Edward C Nemergut
- Departments of *Anesthesiology and †Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Abstract
Thyrotoxic, hypokalaemic periodic paralysis is an uncommon, potentially life-threatening endocrine emergency. Because of the acute onset of neurological symptoms patients often initially present to hospital ED. To reduce patient morbidity and costs of unnecessary investigations, early recognition and appropriate treatment is required. The case of a young man of Singaporean origin is presented to highlight current treatment, management and pathophysiology of this condition.
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Affiliation(s)
- Melissa J Gillett
- Department of Endocrinology and Diabetes, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Hsieh CH, Kuo SW, Pei D, Hung YJ, Chyi-Fan S, Wu LI, He CT, Yang TC, Lian WC, Chien-Hsing L. Thyrotoxic periodic paralysis: an overview. Ann Saudi Med 2004; 24:418-22. [PMID: 15646156 PMCID: PMC6147835 DOI: 10.5144/0256-4947.2004.418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a fairly common manifestation of hyperthyroidism in Asian populations, with an incidence of about 1.9% in thyrotoxic patients, but it is rarely diagnosed among Caucasians and blacks in the Western world. The diagnosis often can be made on the basis of the clinical manifestations alone. Sometimes, periodic paralysis precedes hyperthyroidism or occurs in silent hyperthyroidism. As a result, physicians may easily overlook it even when life-threatening hypokalemia is present. The pathophysiology of this disorder is still not well understood. Correction of the thyrotoxic state is the definitive treatment. Potassium supplementation, propranolol, and spironolactone may be helpful both in the acute state and in preventing attacks.
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Affiliation(s)
- Chang-Hsun Hsieh
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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Hsu FS, Tsai WS, Chau T, Chen HH, Chen YC, Lin SH. Thyrotropin-secreting pituitary adenoma presenting as hypokalemic periodic paralysis. Am J Med Sci 2003; 325:48-50. [PMID: 12544087 DOI: 10.1097/00000441-200301000-00011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Thyrotropin (TSH)-secreting pituitary adenoma presenting with hypokalemic periodic paralysis is extraordinarily rare and may be misdiagnosed. We describe a 44-year-old man who suffered from acute muscle weakness and inability to ambulate upon awakening in the morning. Physical examination showed hypertension, tachycardia, and symmetrical flaccid paralysis of all extremities. The major biochemical abnormality was hypokalemia (K+, 2.0 mmol/L) with low urine K+ excretion. A thyroid function study revealed elevated thyroid hormone levels and inappropriately high TSH concentrations (2.10 microU/mL). Brain magnetic resonance imaging delineated a pituitary tumor with suprasellar extension. After trans-sphenoidal removal of tumor, he became clinically and biochemically euthyroid without any further attack of paralysis. Pathological findings confirmed a TSH-secreting adenoma with exclusive TSH immunostaining. TSH-secreting pituitary adenoma must be kept in the differential diagnosis in any thyrotoxic periodic paralysis patients with detectable TSH levels to avoid delaying diagnosis and management.
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Affiliation(s)
- Feng-Sheng Hsu
- Division of Nephrology, Department of Medicine, Mackay Memorial Hospital, Taipei Taiwan, Republic of China
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Abstract
Pituitary tumors, depending on their respective cell type, manifest various endocrinopathies. Prolactinomas may present as hypogonadism and galactorrhea and can be diagnosed by measuring morning prolactin levels. Gonadotropinomas rarely cause gonadal hyperstimulation, and dynamic thyrotropin-releasing hormone stimulation testing is often required to elicit a diagnostic gonadotropin and/or subunit secretory response. Acromegaly is a multisystemic debilitating disease for which early diagnosis and treatment are crucial. Diagnostic criteria include a lack of plasma growth hormone suppression during the oral glucose tolerance test and elevation of age- and sex-matched insulin growth factor-1 levels. Patients harboring corticotropin-secreting adenomas characheristically present with signs and symptoms of hypercortisolism. Inferior petrosal sinus sampling for corticotropin may be required for microadenoma localization. Thyrotropinomas produce inappropriate thyrotropin (TSH) secretion and hyperthyroidism. The new third-generation TSH assay has improved the rate of detection of these lesions at an earlier stage.
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Affiliation(s)
- Marie F Simard
- Department of Neurosurgery, University of Utah Medical Center, Suite 3B409, 30 North 1900 East, Salt Lake City, UT 84132-2303, USA.
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