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Zheng Y, Wei L, Ang SYL, Ng HL, Au WL, Tay KY, Xu Z, Ng WH, Tan LCS, Neo SX, Wan KR. Outcomes after deep brain stimulation for elderly versus non-elderly patients with Parkinson's disease. Clin Neurol Neurosurg 2024; 242:108319. [PMID: 38723583 DOI: 10.1016/j.clineuro.2024.108319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/30/2024] [Accepted: 05/04/2024] [Indexed: 06/16/2024]
Abstract
INTRODUCTION The decision to offer deep brain stimulation (DBS) to elderly patients with Parkinson's disease (PD) presents challenges due to higher perceived risks and uncertain long-term benefits. Here, we aimed to compare the outcomes after DBS for elderly versus non-elderly patients with PD. METHODS We analyzed data from our institutional cohort and retrieved publicly available data through a systematic review. The exposure was age at DBS electrode insertion, which was defined as elderly (≥70 years old) and non-elderly (<70 years old). The outcomes examined were changes in the Movement Disorders Society-Parkinson's Disease Rating Scale (MDS-UPDRS) or UPDRS part III total score, levodopa-equivalent daily dose (LEDD), and adverse events. RESULTS The included studies and our cohort comprised a total of 527 patients, with 111 (21.1 %) classified as elderly. There was no statistically significant difference in the change in MDS-UPDRS or UPDRS part III total score and generally no statistically significant difference in the change in LEDD between the elderly and non-elderly patients. Elderly patients had a higher incidence of wound infection (elderly 5.4 % vs non-elderly 1.9 %; p = 0.087) and inadequate wound healing (elderly 3.6 % vs non-elderly 1.4 %; p = 0.230), but this difference was not statistically significant. There was no significant difference in the incidence of mortality (elderly 0 % vs non-elderly 0 %; p = 1.000), stroke (elderly 0 % vs non-elderly 0.2 %; p = 1.000), and cognitive decline between the age groups. CONCLUSIONS Notwithstanding the trend towards a higher risk of wound infection and inadequate wound healing, elderly patients have similar motor outcomes and levels of PD medication reduction as non-elderly patients after DBS for PD. Hence, age should not be used as the sole criterion for determining eligibility for DBS, and the decision to offer DBS to elderly patients should be personalized and made in a multidisciplinary setting, taking into consideration patient- and disease-related factors.
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Affiliation(s)
- Yilong Zheng
- SingHealth PGY1 Program, Singapore General Hospital, Singapore
| | - Li Wei
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Samantha Ya Lyn Ang
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
| | - Hwee Lan Ng
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Wing Lok Au
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Kay Yaw Tay
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Zheyu Xu
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
| | | | | | - Kai Rui Wan
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
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Alugolu R, Kolpakwar S, Mudumba V, Arora A, Kandadai R, Borgohain R. Prospective analysis of gross and fine electrode position and motor manifestations after STN-DBS and their correlation with electrode position. J Neurosurg Sci 2024; 68:201-207. [PMID: 34647713 DOI: 10.23736/s0390-5616.21.05461-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) has been proven to be a safe, reversible, cost-effective procedure for treatment of Parkinson's disease. Final electrode position remains a significant factor determining the outcomes of subthalamic nucleus DBS (STN-DBS). This study aims to analyze the final lead position in three-dimensional plane and its effect on gross and fine motor outcomes in cases of advanced Parkinson's disease operated for STN-DBS. METHODS Patients who underwent bilateral STN-DBS were prospectively followed for improvement in gross motor outcomes at 6 months. Improvement in dysgraphia was analyzed by Fahn-Tolosa-Marin Tremor Rating Scale Part B Score. Postoperative outcomes were correlated with final electrode position. RESULTS A total of 64 Patients (128 leads) were analyzed. Patients who were less than 65 years of age at time of surgery had more significant reduction in UPDRS III (P=0.02). Cases with deviation of left x less than 3 mm had significant reduction in UPDRS III (P=0.05) and speech sub-scores (P=0.05). Deviation less than 2 mm in left x was associated with reduction in gait sub-scores (P=0.04). Optimal placement of right y electrode was associated with reduction in UPDRS III (P=0.02). Significant reduction in Fahn-Tolosa-Marin Tremor Rating Scale Part B Score was noted after DBS (P=0.001). CONCLUSIONS Subthalamic nucleus DBS thus results in significantly improved functional outcome particularly in patients with age less than 65 years. Accurate final electrode position is associated with maximum clinical benefit and improvement in dysgraphia.
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Affiliation(s)
- Rajesh Alugolu
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India -
| | - Swapnil Kolpakwar
- Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | - Abhishek Arora
- Department of Radiology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rukmini Kandadai
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rupam Borgohain
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
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Vinke RS, Geerlings M, Selvaraj AK, Georgiev D, Bloem BR, Esselink RA, Bartels RH. The Role of Microelectrode Recording in Deep Brain Stimulation Surgery for Parkinson's Disease: A Systematic Review and Meta-Analysis. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2059-2069. [PMID: 35912752 PMCID: PMC9661327 DOI: 10.3233/jpd-223333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND STN-DBS is a cornerstone in the treatment of advanced Parkinson's disease (PD). The traditional approach is to use an awake operative technique with microelectrode recording (MER). However, more centers start using an asleep MRI-guided technique without MER. OBJECTIVE We systematically reviewed the literature to compare STN-DBS surgery with and without MER for differences in clinical outcome. METHODS We systematically searched PubMed, Embase, MEDLINE, and Web of Science databases for randomized clinical trials and consecutive cohort studies published between 01-01-2000 and 26-08-2021, that included at least 10 PD patients who had received bilateral STN-DBS. RESULTS 2,129 articles were identified. After abstract screening and full-text review, 26 studies were included in the final analysis, comprising a total of 34 study groups (29 MER and 5 non-MER). The standardized mean difference (SMD) in change in motor symptoms between baseline (OFF medication) and 6-24 months follow-up (OFF medication and ON stimulation) was 1.64 for the MER group and 1.87 for non-MER group (p = 0.59). SMD in change in levodopa equivalent daily dose (LEDD) was 1.14 for the MER group and 0.65 for non-MER group (p < 0.01). Insufficient data were available for comparative analysis of PDQ-39 and complications. CONCLUSION The change in motor symptoms from baseline to follow-up did not differ between studies that used MER and those that did not. The postoperative reduction in LEDD from baseline to follow-up was greater in the MER-group. In the absence of high-quality studies comparing both methods, there is a clear need for a well-designed comparative trial.
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Affiliation(s)
- R. Saman Vinke
- Department of Neurosurgery, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin Geerlings
- Department of Neurosurgery, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ashok K. Selvaraj
- Department of Neurosurgery, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dejan Georgiev
- Department of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Artifical Intelligence Laboratory, Faculty of Computer and Information Science, University of Ljubljana, Ljubljana, Slovenia
| | - Bastiaan R. Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rianne A.J. Esselink
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald H.M.A. Bartels
- Department of Neurosurgery, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Mitchell KT, Younce JR, Norris SA, Tabbal SD, Dowling JL, Rich KM, Perlmutter JS, Ushe M. Bilateral Subthalamic Nucleus Deep Brain Stimulation in Elderly Patients With Parkinson Disease: A Case-Control Study. Oper Neurosurg (Hagerstown) 2021; 19:234-240. [PMID: 32259239 DOI: 10.1093/ons/opaa049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 01/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subthalamic nucleus deep brain stimulation (STN DBS) is an effective adjunctive therapy for Parkinson disease. Studies have shown improvement of motor function but often exclude patients older than 75 yr. OBJECTIVE To determine the safety and effectiveness of STN DBS in patients 75 yr and older. METHODS A total of 104 patients (52 patients >75 yr old, 52 patients <75 yr old) with STN DBS were paired and retrospectively analyzed. The primary outcome was change in Unified Parkinson Disease Rating Scale (UPDRS) subscale III at 1 yr postoperatively, OFF medication. Secondary outcomes were changes in UPDRS I, II, and IV subscales and levodopa equivalents. Complications and all-cause mortality were assessed at 30 d and 1 yr. RESULTS Both cohorts had significant improvements in UPDRS III at 6 mo and 1 yr with no difference between cohorts. Change in UPDRS III was noninferior to the younger cohort. The cohorts had similar worsening in UPDRS I at 1 yr, no change in UPDRS II, similar improvement in UPDRS IV, and similar levodopa equivalent reduction. There were similar numbers of postoperative intracerebral hemorrhages (2/52 in each cohort, more severe in the older cohort) and surgical complications (4/52 in each cohort), and mortality in the older cohort was similar to an additional matched cohort not receiving DBS. CONCLUSION STN DBS provides substantial motor benefit and reduction in levodopa equivalents with a low rate of complications in older patients, which is also noninferior to the benefit in younger patients. STN DBS remains an effective therapy for those over 75 yr.
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Affiliation(s)
- Kyle T Mitchell
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - John R Younce
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Samer D Tabbal
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Neurology, American University of Beirut, Beirut, Lebanon
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith M Rich
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joel S Perlmutter
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.,Department of Radiology, Washington University School of Medicine, St. Louis, Missouri.,Department of Neuroscience, Washington University School of Medicine, St. Louis, Missouri.,Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri.,Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri
| | - Mwiza Ushe
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Azevedo P, Aquino CC, Fasano A. Surgical Management of Parkinson's Disease in the Elderly. Mov Disord Clin Pract 2021; 8:500-509. [PMID: 33981782 DOI: 10.1002/mdc3.13161] [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: 10/23/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 11/09/2022] Open
Abstract
Background Deep Brain Stimulation (DBS) is an increasingly popular therapy for Parkinson's Disease (PD). Despite the experience gained over time with DBS of either the subthalamus or the globus pallidus pars interna, there is still no consensus regarding the age limit for DBS indication. Objectives This narrative review of the literature discusses the issues of age and DBS, emphasizing the critical need for good quality evidence to support the surgical management of elderly patients with PD. Methods We searched PubMed using the terms Parkinson's Disease; Parkinson's Disease therapy; deep brain stimulation; antiparkinsonian agents therapeutic use; age factors; aged; aged, 80 and over; middle aged; treatment outcome; and risk assessments. Results We identified several limitations of the available evidence, such as under-representation of older patients in DBS studies, small sample sizes in studies with older participants, heterogeneity of outcomes, and conflicting results. Conclusions Despite preliminary suggestions that age might affect the outcomes of DBS, the evidence to support the hypothesis of age as an independent predictor of DBS outcomes is limited and results are controversial. Ultimately, finding an age-independent biomarker predicting DBS outcome is the final goal to expand this powerful treatment to all patients age in an effective and safe manner.
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Affiliation(s)
- Paula Azevedo
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology University of Toronto Toronto Ontario Canada
| | - Camila C Aquino
- Department of Clinical Neurosciences University of Calgary Calgary Alberta Canada.,Hotchkiss Brain Institute, University of Calgary Calgary Alberta Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology University of Toronto Toronto Ontario Canada.,Krembil Brain Institute Toronto Ontario Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA) Toronto Ontario Canada
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Bullard AJ, Hutchison BC, Lee J, Chestek CA, Patil PG. Estimating Risk for Future Intracranial, Fully Implanted, Modular Neuroprosthetic Systems: A Systematic Review of Hardware Complications in Clinical Deep Brain Stimulation and Experimental Human Intracortical Arrays. Neuromodulation 2019; 23:411-426. [DOI: 10.1111/ner.13069] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Autumn J. Bullard
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | | | - Jiseon Lee
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Electrical Engineering and Computer Science University of Michigan Ann Arbor MI USA
| | - Parag G. Patil
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Neurosurgery University of Michigan Medical School Ann Arbor MI USA
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Matsuura K, Maeda M, Satoh M, Tabei KI, Araki T, Umino M, Kajikawa H, Nakamura N, Tomimoto H. Low Pulvinar Intensity in Susceptibility-Weighted Imaging May Suggest Cognitive Worsening After Deep Brain Stimulation Therapy in Patients With Parkinson's Disease. Front Neurol 2019; 10:1158. [PMID: 31736863 PMCID: PMC6834769 DOI: 10.3389/fneur.2019.01158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/15/2019] [Indexed: 01/19/2023] Open
Abstract
Purpose: Deep brain stimulation (DBS) is an established therapy for Parkinson's disease (PD). However, deteriorating cognitive function after DBS is a considerable problem for affected patients. This study was undertaken to assess whether pulvinar findings in susceptibility-weighted imaging (SWI) can suggest cognitive worsening. Methods: We examined 21 patients with PD who underwent DBS along with SWI and neuromelanin-sensitive MR imaging (NMI). We further assessed pulvinar hypointensity based on the SWI findings and also the area of the substantia nigra (SN) pars compacta in NMI. We then examined associations among cognitive changes, pulvinar hypointensity, and SN area. The cognitive function of the patient immediately before surgery was compared with function at 1 year postoperatively. Results: Pulvinar hypointensity in SWI was found in 11 of 21 patients with PD at baseline. One year postoperatively, six of the 21 patients demonstrated a Mini-Mental State Examination score that was ≥3 points lower than the baseline score. We observed pulvinar hypointensity in SWI before DBS surgery in five of these six patients (p = 0.072). During the first postoperative year, six of 21 patients reported both transient or permanent hallucinations; we observed pulvinar hypointensity in these six patients, while 10 patients without pulvinar hypointensity had no hallucinations. Conclusion: Pulvinar hypointensity in SWI in patients with PD may provide information that is useful for suggesting cognitive deterioration after DBS treatment.
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Affiliation(s)
- Keita Matsuura
- Department of Neurology, Graduate School of Medicine, Mie University, Tsu, Japan.,Department of Neurology, Suzuka Kaisei Hospital, Suzuka, Japan
| | - Masayuki Maeda
- Department of Advanced Diagnostic Imaging, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Masayuki Satoh
- Dementia Prevention and Therapeutics, Mie University, Tsu, Japan
| | - Ken-Ichi Tabei
- Dementia Prevention and Therapeutics, Mie University, Tsu, Japan
| | - Tomohiro Araki
- Department of Neurosurgery, Suzuka Kaisei Hospital, Suzuka, Japan
| | - Maki Umino
- Department of Radiology, Graduate School of Medicine, Mie University, Tsu, Japan
| | | | - Naoko Nakamura
- Department of Neurology, Suzuka Kaisei Hospital, Suzuka, Japan
| | - Hidekazu Tomimoto
- Department of Neurology, Graduate School of Medicine, Mie University, Tsu, Japan
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Hanna JA, Scullen T, Kahn L, Mathkour M, Gouveia EE, Garces J, Evans LM, Lea G, Houghton DJ, Biro E, Bui CJ, Sulaiman OA, Smith RD. Comparison of elderly and young patient populations treated with deep brain stimulation for Parkinson's disease: long-term outcomes with up to 7 years of follow-up. J Neurosurg 2019; 131:807-812. [PMID: 30265192 DOI: 10.3171/2018.4.jns171909] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 04/17/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is the procedure of choice for Parkinson's disease (PD). It has been used in PD patients younger than 70 years because of better perceived intra- and postoperative outcomes than in patients 70 years or older. However, previous studies with limited follow-up have demonstrated benefits associated with the treatment of elderly patients. This study aims to evaluate the long-term outcomes in elderly PD patients treated with DBS in comparison with a younger population. METHODS PD patients treated with DBS at the authors' institution from 2008 to 2014 were divided into 2 groups: 1) elderly patients, defined as having an age at surgery ≥ 70 years, and 2) young patients, defined as those < 70 years at surgery. Functional and medical treatment outcomes were evaluated using the Unified Parkinson's Disease Rating Scale part III (UPDRS III), levodopa-equivalent daily dose (LEDD), number of daily doses, and number of anti-PD medications. Study outcomes were compared using univariate analyses, 1-sample paired t-tests, and 2-sample t-tests. RESULTS A total of 151 patients were studied, of whom 24.5% were ≥ 70 years. The most common preoperative Hoehn and Yahr stages for both groups were 2 and 3. On average, elderly patients had more comorbidities at the time of surgery than their younger counterparts (1 vs 0, p = 0.0001) as well as a higher average LEDD (891 mg vs 665 mg, p = 0.008). Both groups experienced significant decreases in LEDD following surgery (elderly 331.38 mg, p = 0.0001; and young 108.6 mg, p = 0.0439), with a more significant decrease seen in elderly patients (young 108.6 mg vs elderly 331.38 mg, p = 0.0153). Elderly patients also experienced more significant reductions in daily doses (young 0.65 vs elderly 3.567, p = 0.0344). Both groups experienced significant improvements in motor function determined by reductions in UPDRS III scores (elderly 16.29 vs young 12.85, p < 0.0001); however, reductions in motor score between groups were not significant. Improvement in motor function was present for a mean follow-up of 3.383 years postsurgery for the young group and 3.51 years for the elderly group. The average follow-up was 40.6 months in the young group and 42.2 months in the elderly group. CONCLUSIONS This study found long-term improvements in motor function and medication requirements in both elderly and young PD patients treated with DBS. These outcomes suggest that DBS can be successfully used in PD patients ≥ 70 years. Further studies will expand on these findings.
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Affiliation(s)
- Joshua A Hanna
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Tyler Scullen
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Lora Kahn
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | | | - Juanita Garces
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | | | - Georgia Lea
- 3Movement Disorders, Ochsner Clinic Foundation, New Orleans; and
| | - David J Houghton
- 3Movement Disorders, Ochsner Clinic Foundation, New Orleans; and
| | - Erin Biro
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Cuong J Bui
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Olawale A Sulaiman
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
| | - Roger D Smith
- Departments of1Neurosurgery and
- 2Department of Neurosurgery, Tulane Medical Center, New Orleans, Louisiana
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