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Luchtmann M, Klammer A, Iova MA, Roth A, Chanamolu VK, Mawrin C, Warnke JP. Thecaloscopy Reduces the Risk of Recurrent Perineural (Tarlov) Cysts after Microsurgical Resection. Neurol Int 2024; 16:450-458. [PMID: 38668130 PMCID: PMC11054917 DOI: 10.3390/neurolint16020033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024] Open
Abstract
Sacral Tarlov cysts (TCs), often asymptomatic, can cause significant pain and severe neurological dysfunction. Conventional treatments are generally associated with high recurrence and complication rates. Specifically, the substantial recurrence rates, which can reach as high as 50%, significantly impact long-term outcomes. Recent evidence increasingly supports the hypothesis that the formation of Tarlov cysts (TCs) may be associated with inflammatory processes within the nerve root sheath, further exacerbated by elevated cerebrospinal fluid (CSF) pressure. This retrospective study explores thecaloscopy, combined with surgical techniques, as a more effective alternative. We observed a total of 78 patients, 48 of whom underwent endoscopic fenestration of the arachnoid sheath in addition to microsurgical resection of the TC. We found that the fenestration of the arachnoid sheath at the level of lumbosacral spinal nerve root entry led to a significantly decreased risk of developing recurrent TCs (5/48 vs. 9/30). Only one of the patients suffered from a persistent new bladder dysfunction after microsurgical resection. This presented technique provides a promising treatment path for the future management of TCs, offering a safe and more effective treatment option compared to previous methods. Additionally, the advantages of the thecaloscopy provide pathophysiological implications regarding the development of perineural cysts.
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Affiliation(s)
- Michael Luchtmann
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Leupold Institute for Applied Natural Sciences, University of Applied Science, 08056 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
| | - Angelika Klammer
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
| | - Mircea-Alin Iova
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - André Roth
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - Vijay Kumar Chanamolu
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - Christian Mawrin
- Vigdis Thompson Foundation, 08412 Werdau, Germany
- Department of Neuropathology, Otto-von-Guericke University, 39120 Magdeburg, Germany
| | - Jan-Peter Warnke
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
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Hulens M, Bruyninckx F, Thal DR, Rasschaert R, Bervoets C, Dankaerts W. Large- and Small-Fiber Neuropathy in Patients with Tarlov Cysts. J Pain Res 2022; 15:193-202. [PMID: 35115823 PMCID: PMC8801331 DOI: 10.2147/jpr.s342759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/08/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mieke Hulens
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Correspondence: Mieke Hulens, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, Leuven, Belgium, Tel +32 478 338003, Fax +32 16 32 91 97, Email
| | - Frans Bruyninckx
- Department of Physical Medicine & Rehabilitation, EMG-Laboratory, University Hospitals of Leuven, Leuven, Belgium
| | - Dietmar Rudolf Thal
- Department of Imaging and Pathology, Laboratory of Neuropathology, and Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals of Leuven, Leuven, Belgium
| | | | - Chris Bervoets
- Department of Neurosciences, Adult Psychiatry, KU Leuven, Leuven, Belgium
- Department of Ophthalmology, University Hospitals of Leuven, Leuven, Belgium
- Department Adult Psychiatry, University Psychiatric Center of KU Leuven, Leuven, Belgium
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Cheng SJ, Hakkinen I, Zhang P, Roychowdhury S. Paradoxical headache in a case of chronic spontaneous intracranial hypotension and multiple perineural cysts. Headache 2021; 61:1291-1294. [PMID: 34510443 DOI: 10.1111/head.14188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha J Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Ian Hakkinen
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Pengfei Zhang
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Sudipta Roychowdhury
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Hulens M, Bruyninckx F, Dankaerts W, Rasschaert R, De Mulder P, Stalmans I, Vansant G, Bervoets C. High Prevalence of Perineural Cysts in Patients with Fibromyalgia and Chronic Fatigue Syndrome. PAIN MEDICINE 2021; 22:883-890. [PMID: 33260218 DOI: 10.1093/pm/pnaa410] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Pain in fibromyalgia (FM) and chronic fatigue syndrome (CFS) is assumed to originate from central sensitization. Perineural cysts or Tarlov cysts (TCs) are nerve root dilations resulting from pathologically increased cerebrospinal fluid pressure. These cysts initially affect sensory neurons and axons in dorsal root ganglia and produce sensory symptoms (pain and paresthesia). Symptomatic TC (STC) patients often complain about widespread pain and fatigue. Consequently, STC patients may initially be diagnosed with FM, CFS, or both. The objective of this study was to document the prevalence of TCs in patients diagnosed with FM or CFS. DESIGN A retrospective study. SETTING An outpatient clinic for musculoskeletal disorders. SUBJECTS Patients diagnosed with FM according to the 1990 American College of Rheumatology criteria or with CFS according to the 1994 Centers for Disease Control criteria were selected. METHODS Review of lumbar and sacral magnetic resonance imaging scans including TCs ≥5 mm in size. RESULTS In total, 197 patients with FM, CFS, or both underwent magnetic resonance imaging. Ninety-one percent were women. The mean age was 48.1 (±11.9) years. TCs were observed in 39% of patients, with a mean size of 11.8 (±5.2) mm. In males, the prevalence was 12%, vs. 42% in females. CONCLUSIONS In patients diagnosed with FM or CFS, the prevalence of TCs was three times higher than that in the general population. This observation supports the hypothesis that STCs, FM, and CFS may share the same pathophysiological mechanism, i.e., moderately increased cerebrospinal fluid pressure, causing irritation of neurons and axons in dorsal root ganglia.
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Affiliation(s)
- Mieke Hulens
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Frans Bruyninckx
- Clinical Electromyography Laboratory, Department of Academic Consultants, Faculty of Medicine, University Hospitals UZ Leuven, Leuven, Belgium
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | | | - Peter De Mulder
- Department of Anesthesiology and Pain Therapy, Imelda Hospital, Bonheiden, Belgium
| | - Ingeborg Stalmans
- Department of Neurosciences, Ophthalmology Research Group, University of Leuven, Leuven, Belgium.,Department of Ophthalmology, University Hospitals UZ Leuven, Leuven, Belgium
| | - Greet Vansant
- Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Leuven, Belgium
| | - Chris Bervoets
- Department of Neurosciences, Adult Psychiatry, University of Leuven, Leuven, Belgium.,Department of Ophthalmology , University Hospitals UZ Leuven, Leuven, Belgium.,Department Adult Psychiatry, University Psychiatric Center UPC, University of Leuven, Leuven, Belgium
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Hulens M, Dankaerts W, Rasschaert R, Bruyninckx F, Stalmans I, Vansant G, De Mulder P. Hydrocephalus associated with multiple Tarlov cysts. Med Hypotheses 2019; 130:109293. [PMID: 31383334 DOI: 10.1016/j.mehy.2019.109293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/15/2022]
Abstract
Tarlov cysts (TCs) consist of dilated nerve root sheaths filled with cerebrospinal fluid (CSF) and are most frequently found in the sacrum. It is estimated that 25% of detected TCs cause chronic pain and intestinal and urogenital symptoms due to compression of the sacral nerve root fibers inside the TC. Unfortunately, symptomatic TCs are frequently overlooked. It is assumed that TCs result from pathologically increased hydrostatic pressure (HP) in the dural sac that forces CSF into the nerve root sheaths. We hypothesize that in patients with TCs, increased spinal hydrostatic pressure is always associated with increased intracranial pressure. This hypothesis of increased cerebrospinal pressure might explain why patients with sacral TCs frequently report distant symptoms, such as headaches and pain in the neck and arms. In this paper, we describe a case report that provides evidence for this hypothesis. A 30-year-old man presented for the first time in our clinic complaining of lower back, leg, thoracic, neck, and arm pain; headaches; and bladder, bowel, and sphincter symptoms. He was born prematurely and suffered cerebral intraventricular bleeding followed by progressive hydrocephalus. Progression was stabilized with acetazolamide and lumbar punctures. At 19 years of age, his head circumference had further increased and he reported back pain and headaches. Fundoscopy showed no papilledema, and lumbar puncture for CSF evacuation improved the headaches and back pain. The former medical team chose not to insert a ventriculo-external shunt. Brain magnetic resonance imaging (MRI) showed significant dilation of all the ventricles. No CSF flow obstruction between the ventricles was observed. Surprisingly, MRI of the lumbar and sacral spine showed multiple large TCs. This case report indicates that hydrocephalus with a patent aqueduct may be associated with TCs because the increased intracranial pressure is transferred to the spinal canal. While increased intracranial pressure causes dilation of the ventricles, the associated increased spinal pressure may cause dilation of multiple spinal nerve root sheaths to form TCs. Furthermore, while the increased volume of the ventricles gradually compresses the neurons and axons of the brain against the bony skull, simultaneously, the increased pressure inside the nerve sheaths may also gradually compress the neurons and axons located inside the dorsal root ganglia and spinal nerves, resulting in neuropathic pain, sensory abnormalities, and neurogenic bladder and bowel symptoms. Hydrocephalus patients reporting neuropathic pain should be screened for the presence of TCs.
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Affiliation(s)
- Mieke Hulens
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001 Heverlee, Belgium.
| | - Wim Dankaerts
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001 Heverlee, Belgium
| | - Ricky Rasschaert
- Department of Neurosurgery, AZ Rivierenland, Kasteelstraat 23, 2880 Bornem, Belgium
| | - Frans Bruyninckx
- Clinical Electromyography Laboratory, University Hospitals UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Ingeborg Stalmans
- Department of Neurosciences, Ophthalmology Research Group, University of Leuven, 3000 Leuven, Belgium; Department of Ophthalmology, University Hospitals UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Greet Vansant
- Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Peter De Mulder
- Department of Anesthesiology and Pain Therapy, Imelda Hospital, 2820 Bonheiden, Belgium
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Bert RJ, Settipalle N, Tiwana E, Muddasani D, Nath R, Wellman B, Mihlon F, Negahdar M, Amini A, Boakye M. The relationships among spinal CSF flows, spinal cord geometry, and vascular correlations: evidence of intrathecal sources and sinks. Am J Physiol Regul Integr Comp Physiol 2019; 317:R470-R484. [PMID: 31242020 DOI: 10.1152/ajpregu.00101.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We studied relationships of cerebral spinal fluid (CSF) pulsatile flow at cervical, thoracic, and lumbar levels using phase-contrast cine MRI (PCCMRI) to determine the following: 1) instantaneous and average net flows at cervical, thoracic, and lumbar levels, 2) stochastic correlations of CSF flow with major arterial supplies and major draining veins, and 3) whether adjustments of cord-flow curves-using cord cross-sectional areas, caudal lengths, and caudal volumes-would normalize flow curves from different levels. We scanned 15 healthy volunteers without anesthesia, ages 23-46 yr, using external, retrocardiac-gated, two-dimensional PCCMRI at 3T. Transverse scans of the subarachnoid space, arteries, and veins were acquired and analyzed at cervical, thoracic, and lumbar levels. Instantaneous CSF flow decreased craniocaudally along the full time course of a cardiac cycle. Downward net flow generally increased craniocaudally. During diastole, instantaneous CSF flow decreased proportionally to cross-sectional area, caudal residual length, and caudal residual volume of the cord. The proportionalities were less consistent during systole. CSF, internal carotid artery (ICA), vertebral artery, and lower aorta temporal correlations were highest in systole and decreased craniocaudally. CSF flow temporally correlated better with lower aorta flow than with the ICA at T7 and L2 during systole but not diastole. Inferior vena cava temporal correlation increased craniocaudally. We conclude that whereas instantaneous flow is attenuated cranial caudally, net downward flow, per cardiac cycle, increases caudally, becoming statistically significant at T7 and below the conus medullaris. We can explain the results with the assumption of cord CSF production and peripheral-dominated CSF absorption.
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Affiliation(s)
- Robert J Bert
- Department of Radiology, University of Louisville, Louisville, Kentucky
| | - Neesha Settipalle
- Department of Internal Medicine, St. Michael's Medical Center, Newark, New Jersey
| | - Emily Tiwana
- Department of Radiology, University of Louisville, Louisville, Kentucky
| | - Dheeraj Muddasani
- Department of Radiology, University of Louisville, Louisville, Kentucky
| | - Ruponti Nath
- Speed School of Electrical and Computer Engineering, University of Louisville, Louisville, Kentucky
| | - Brandon Wellman
- Department of Radiology, University of Louisville, Louisville, Kentucky
| | - Frank Mihlon
- Hampton Roads Radiology Associates, PA, Norfolk, Virginia
| | | | - Amir Amini
- Speed School of Electrical and Computer Engineering, University of Louisville, Louisville, Kentucky
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
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Hulens M, Rasschaert R, Bruyninckx F, Dankaerts W, Stalmans I, De Mulder P, Vansant G. Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 28:2237-2248. [PMID: 31079249 DOI: 10.1007/s00586-019-05996-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 04/05/2019] [Accepted: 05/05/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked. METHODS The literature was searched for data regarding pathogenesis and symptomatology. RESULTS TCs may be overlooked for the following reasons: (1) STCs are considered clinically irrelevant findings; (2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain; (3) MRI or electromyography studies only focus on the L1 to S1 nerves; (4) TCs are usually not reported by radiologists; (5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain; (6) it is not generally known that small TCs can be symptomatic; (7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery; (8) bladder, bowel and sphincter dysfunction are not inquired about during history taking. (9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain. (10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing. CONCLUSION There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Mieke Hulens
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium. .,, Sint-Joris-Weert, Belgium.
| | - Ricky Rasschaert
- Department of Neurosurgery, AZ Rivierenland, Kasteelstraat 23, 2880, Bornem, Belgium
| | - Frans Bruyninckx
- Clinical Electromyography Laboratory, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Dankaerts
- Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium
| | - Ingeborg Stalmans
- Ophthalmology Research Group, Department of Neurosciences, University of Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Ophthalmology, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Peter De Mulder
- Department of Anesthesiology and Pain Therapy, Imelda Hospital, 2820 Bonheiden, Belgium
| | - Greet Vansant
- Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Herestraat 49, 3000, Leuven, Belgium
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Arenaza Basterrechea N, Macarrón Vicente J, Aícua Rapún I, Porqueres Bosch E. Quistes aracnoideos espinales, una causa inusual de cefalea de esfuerzo. Neurologia 2016; 31:579-80. [DOI: 10.1016/j.nrl.2014.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/16/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022] Open
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Arenaza Basterrechea N, Macarrón Vicente J, Aícua Rapún I, Porqueres Bosch E. Spinal arachnoid cysts as an unusual cause of exercise headache. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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González-Bonet LG, Ortiz-Sánchez P, Barcia-Mariño C. Paroxysmal radiculopathy associated to raised CSF pressure in a patient with spinal meningeal cysts. Clin Neurol Neurosurg 2011; 113:332-4. [PMID: 21269760 DOI: 10.1016/j.clineuro.2010.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Revised: 12/03/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
Affiliation(s)
- L G González-Bonet
- Department of Neurosurgery, Consorcio Hospital General Universitario de Valencia, Spain.
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Brass SD, Dinkin MJ, Williams Z, Krishnamoorthy KS, Copen WA, Freeman SH. Case Records of the Massachusetts General Hospital. Case 38-2009 - a 16-year-old boy with paroxysmal headaches and visual changes. N Engl J Med 2009; 361:2367-78. [PMID: 20007563 DOI: 10.1056/nejmcpc0905547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Steven D Brass
- Department of Neurology, Massachusetts General Hospital, USA
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