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Shakir M, Khowaja AH, Shariq SF, Irshad HA, Tahir I, Rae AI, Hamzah R, Gupta S, Park KB, Enam SA. Financing of Neurosurgical Care for Brain Tumors in Low- and Middle-Income Countries : A Scoping Review of Barriers and Strategies. World Neurosurg 2024; 189:473-482.e3. [PMID: 38901484 DOI: 10.1016/j.wneu.2024.06.067] [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: 06/08/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Making neurosurgical care accessible to a larger portion of the population in low- and middle-income countries (LMICs) is integral due to the high mortality and morbidity associated with brain tumors. However, the high cost of care often makes it financially out of reach for many individuals. Therefore, this review aims to identify barriers to neurosurgical care of brain tumors in terms of financing in LMICs. METHODS Without restriction to language, a search of the literature was undertaken in a number of databases, including PubMed, Scopus, Google Scholar, and CINAHL, in order to find the most pertinent research involving financing of brain tumors in LMICs. The last day of the search was October 20, 2022. Following screening and data extraction, significant themes were found and categorized using thematic analysis. RESULTS A total of 28 studies were analyzed in this review. The review highlighted some of the barriers to providing surgical care of brain tumors in LMICs. In the cited studies, surgical expenses (41%), neuroimaging costs (30%), and care-related expenses (33%) were the primary concerns. Addressing these challenges involves cross-border collaboration (23%), transparent financing systems (46%), awake craniotomy (15%), cost-effective/reusable intra-operative supplies (8%), and optimizing resources in healthcare systems (8%). CONCLUSIONS This study explored barriers and challenges to financing neurosurgical care of brain tumors in LMICs. Government support and transparency in healthcare financing should be prioritized to ensure that all individuals have access to surgical care of brain tumors.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department Aga Khan University Hospital, Karachi, Pakistan.
| | | | | | | | - Izza Tahir
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Ali I Rae
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Radzi Hamzah
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Saksham Gupta
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Kee B Park
- Department of Global Health and Social Medicine, Program for Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department Aga Khan University Hospital, Karachi, Pakistan
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2
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Schaumann A, Hammar C, Alsleben S, Schulz M, Grün A, Lankes E, Tietze A, Koch A, Hernáiz Driever P, Thomale UW. Neurosurgical treatment of pediatric brain tumors - results from a single center multidisciplinary setup. Childs Nerv Syst 2024; 40:381-393. [PMID: 37730915 PMCID: PMC10837233 DOI: 10.1007/s00381-023-06123-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The challenge of pediatric brain tumor surgery is given due to a relative low prevalence but high heterogeneity in age, localization, and pathology. Improvements of long-term overall survival rates were achieved during the past decades stressing the importance of a multidisciplinary decision process guided by a national treatment protocol. We reviewed the entire spectrum of pediatric brain tumor surgeries from the perspective of an interdisciplinary pediatric neuro-oncology center in Germany. METHODS Every patient who underwent brain tumor surgery from January 2010 to June 2017 in our Pediatric Neurosurgery department was retrospectively included and evaluated regarding the course of treatment. Perioperative data such as tumor localization, timing of surgery, extent of resection, neuropathological diagnosis, transfusion rates, oncologic and radiation therapy, and neurological follow-up including morbidity and mortality were evaluated. RESULTS Two hundred ninety-three pediatric brain tumor patients were applicable (age: 8.28 ± 5.62 years, 1.22:1.0 m:f). A total of 531 tumor surgical interventions was performed within these patients (457 tumor resections, 74 tumor biopsies; mean interventions per patient 1.8 ± 1.2). Due to a critical neurologic status, 32 operations (6%) were performed on the day of admission. In 65.2% of all cases, tumor were approached supratentorially. Most frequent diagnoses of the cases were glial tumors (47.8%) and embryonal tumors (17.6%). Preoperative planned extent of resection was achieved in 92.7%. Pre- and postoperative neurologic deficits resolved completely in 30.7%, whereas symptom regressed in 28.6% of surgical interventions. New postoperative neurologic deficit was observed in 10.7%, which resolved or improved in 80% of these cases during 30 days. The mortality rate was 1%. CONCLUSION We outlined the center perspective of a specialized pediatric neuro-oncological center describing the heterogeneous distribution of cases regarding age-related prevalence, tumor localization, and biology, which requires a high multidisciplinary expertise. The study contributes to define challenges in treating pediatric brain tumors and to develop quality indicators for pediatric neuro-oncological surgery. We assume that an adequate volume load of patients within a interdisciplinary infrastructure is warranted to aim for effective treatment and decent quality of life for the majority of long-term surviving pediatric tumor patients.
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Affiliation(s)
- A Schaumann
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Pediatric Neurosurgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - C Hammar
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Pediatric Neurosurgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - S Alsleben
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Pediatric Neurosurgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - M Schulz
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Pediatric Neurosurgery, Augustenburger Platz 1, 13353, Berlin, Germany
| | - A Grün
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department for Radiation Oncology and Radiotherapy, Augustenburger Platz 1, 13353, Berlin, Germany
| | - E Lankes
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Endocrinology and Diabetes, Augustenburger Platz 1, 13353, Berlin, Germany
| | - A Tietze
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Arend Koch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuropathology, Berlin, Germany
| | - P Hernáiz Driever
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Pediatric Hematology and Oncology, Augustenburger Platz 1, 13353, Berlin, Germany
| | - U-W Thomale
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Pediatric Neurosurgery, Augustenburger Platz 1, 13353, Berlin, Germany.
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3
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Thomale UW, Gnekow AK, Kandels D, Bison B, Hernáiz Driever P, Witt O, Pietsch T, Koch A, Capper D, Kortmann RD, Timmermann B, Harrabi S, Simon M, El Damaty A, Krauss J, Schuhmann MU, Aigner A. Long-term follow-up of surgical intervention pattern in pediatric low-grade gliomas: report from the German SIOP-LGG 2004 cohort. J Neurosurg Pediatr 2022; 30:316-329. [PMID: 35901673 DOI: 10.3171/2022.6.peds22108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neurosurgical treatment is an integral part of the treatment algorithms for pediatric low-grade glioma (LGG), yet patterns of surgical procedures are rarely challenged. The objective of this study was to evaluate surgical treatment patterns in pediatric LGG. METHODS The German Societé Internationale d'Oncologie Pédiatrique (SIOP)-LGG 2004 cohort was analyzed to identify relevant patient and tumor characteristics associated with time to death, next surgery, number of resections, and radiological outcome. RESULTS A total of 1271 patients underwent 1713 neurosurgical interventions (1 intervention in 947, 2 in 230, 3 in 70, and 4-6 in 24). The median age of the study population was 8.57 years at first surgery, and 46.1% were female. Neurofibromatosis type 1 (NF1) was found in 4.4%, and 5.4% had tumor dissemination. Three hundred fifty-four patients (27.9%) had chemotherapy and/or radiotherapy. The cumulative incidence of second surgery at 10 years was 26%, and was higher for infants, those with spinal and supratentorial midline (SML) tumors, and those with pilomyxoid astrocytomas. The hazard ratio for subsequent surgery was higher given dissemination and noncomplete initial resection, and lower for caudal brainstem and SML tumors. Among 1225 patients with fully documented surgical records and radiological outcome, 613 reached complete remission during the observation period, and 50 patients died. Patients with pilocytic astrocytoma had higher chances for a final complete remission, whereas patients with initial partial or subtotal tumor resection, dissemination, NF1, or primary tumor sites in the spinal cord and SML had lower chances. CONCLUSIONS Neurosurgery is a key element of pediatric LGG treatment. In almost 50% of the patients, however, at least some tumor burden will remain during long-term follow-up. This study found that most of these patients reached a stable disease status without further surgeries. Multidisciplinary team decisions must balance the goal of complete resection, risk factors, repeated surgeries, and possible treatment alternatives in a wide range of heterogeneous entities. Procedural details and neurological outcome should be recorded to better assess their impact on long-term outcome.
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Affiliation(s)
- Ulrich-Wilhelm Thomale
- 1Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Astrid K Gnekow
- 2Pediatric and Adolescent Medicine, Swabian Children's Cancer Research Center, Medical Faculty, University of Augsburg
| | - Daniela Kandels
- 2Pediatric and Adolescent Medicine, Swabian Children's Cancer Research Center, Medical Faculty, University of Augsburg
| | - Brigitte Bison
- 3Institute of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg
- 4Institute of Diagnostic and Interventional Neuroradiology, Medical Faculty, University of Augsburg
| | - Pablo Hernáiz Driever
- 5Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Olaf Witt
- 6Hopp Children's Cancer Center Heidelberg (KiTZ), German Cancer Research Center (DKFZ), and Heidelberg University Hospital, Heidelberg
| | - Torsten Pietsch
- 7Department of Neuropathology, DGNN Brain Tumor Reference Centre, University of Bonn Medical Centre, Bonn
| | - Arend Koch
- 8Institute for Neuropathology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - David Capper
- 8Institute for Neuropathology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | | | - Beate Timmermann
- 10Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen
| | - Semi Harrabi
- 11Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg
| | - Michèle Simon
- 5Department of Pediatric Oncology/Hematology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin
| | - Ahmed El Damaty
- 12Division of Pediatric Neurosurgery, Department of Neurosurgery, Heidelberg University Hospital, Heidelberg
| | - Juergen Krauss
- 13Department of Pediatric Neurosurgery, University Children's Hospital, University of Würzburg
| | - Martin U Schuhmann
- 14Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Eberhard Karls University of Tuebingen; and
| | - Annette Aigner
- 15Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
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Intraoperative MRI versus intraoperative ultrasound in pediatric brain tumor surgery: is expensive better than cheap? A review of the literature. Childs Nerv Syst 2022; 38:1445-1454. [PMID: 35511271 DOI: 10.1007/s00381-022-05545-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The extent of brain tumor resection (EOR) is a fundamental prognostic factor in pediatric neuro-oncology in association with the histology. In general, resection aims at gross total resection (GTR). Intraoperative imaging like intraoperative US (iOUS) and MRI have been developed in order to find any tumoral remnant but with different costs. Aim of our work is to review the current literature in order to better understand the differences between costs and efficacy of MRI and iOUS to evaluate tumor remnants intraoperatively. METHODS We reviewed the existing literature on PubMed until 31st December 2021 including the sequential keywords "intraoperative ultrasound and pediatric brain tumors", "iUS and pediatric brain tumors", "intraoperative magnetic resonance AND pediatric brain tumors", and "intraoperative MRI AND pediatric brain tumors. RESULTS A total of 300 papers were screened through analysis of title and abstract; 254 were excluded. After selection, a total of 23 articles were used for this systematic review. Among the 929 patients described, a total of 349(38%) of the cases required an additional resection after an iMRI scan. GTR was measured on 794 patients (data of 69 patients lost), and it was achieved in 552(70%) patients. In case of iOUS, GTR was estimated in 291 out of 379 (77%) cases. This finding was confirmed at the post-operative MRI in 256(68%) cases. CONCLUSIONS The analysis of the available literature demonstrates that expensive equipment does not always mean better. In fact, for the majority of pediatric brain tumors, iOUS is comparable to iMRI in estimating the EOR.
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Muhsen BA, Aljariri AI, Elayyan M, Hirbawi H, Masri MA. Insight about the characteristics and surgical resectability of adult pilocytic astrocytoma: tertiary center experience. CNS Oncol 2022; 11:CNS81. [PMID: 35382555 PMCID: PMC8988253 DOI: 10.2217/cns-2021-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/08/2022] [Indexed: 12/13/2022] Open
Abstract
Aim: Adult pilocytic astrocytoma is a rare tumor. We aim to contribute to understanding its clinical course and prognosis. Patients & methods: We searched our database for patients older than 18 years with pathology-proven pilocytic astrocytoma. Patients' clinical data were analyzed. Results: Fifteen patients were identified. The median age at diagnosis was 25 years (range: 18-56). Tumors were supratentorial in 47%. Gross-total and near-total resections were achieved in 40%, and sub-total resection in 47%. One (7%) recurrence and no mortality were encountered during a median follow-up of 11 months (range: 1-76). Conclusion: Pilocytic astrocytoma behaves differently in adults compared with pediatrics. It tends to arise in surgically challenging areas where the extent of resection may be limited. Total resection should be the main therapy whenever feasible. The survival rates are good, and recurrence is low.
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Affiliation(s)
- Baha'eddin A Muhsen
- Division of Neurosurgery, Department of Surgery, King Hussein Cancer Center, Amman, 11941, Jordan
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | | | - Maher Elayyan
- Division of Neurosurgery, Department of Surgery, King Hussein Cancer Center, Amman, 11941, Jordan
| | - Hawazen Hirbawi
- Department of Medicine, Istishari Hospital, Amman, 11194, Jordan
| | - Mahmoud A Masri
- Department of Surgery, King Hussein Cancer Center, Amman, 11941, Jordan
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Baker C, Crevelt J, Whipple N, Bollo RJ, Cheshier S. Treatment of a symptomatic thalamic pilocytic astrocytoma with reservoir placement and laser interstitial thermal therapy: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21363. [PMID: 36209402 PMCID: PMC9379627 DOI: 10.3171/case21363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of pilocytic astrocytomas (PAs) in children can be challenging when they arise in deep midline structures because complete surgical resection may result in significant neurological injury. Laser interstitial thermal therapy (LITT) has provided an alternative treatment modality for lesions that may not be amenable to resection. However, many patients with PAs may be symptomatic from a compressive cyst associated with the PA, and LITT does not obviate the need for cystic decompression in these patients. OBSERVATIONS A 12-year-old male presented with left-sided weakness. Magnetic resonance imaging (MRI) revealed an enhancing mass with a large cyst involving the right thalamus and basal ganglia. The patient underwent a reservoir placement for cyst drainage and biopsy of the mass, revealing a pilocytic astrocytoma. He then underwent LITT followed by adjuvant chemotherapy. Sixteen months after LITT, follow-up MRI of the brain revealed no tumor growth. LESSONS This is the first case to describe reservoir placement to treat the cystic portion of a pilocytic astrocytoma followed by LITT and targeted chemotherapy. Reservoir placement reduced the cyst’s mass effect and resolved the patient’s symptoms, allowing for treatment options beyond resection.
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Affiliation(s)
- Cordell Baker
- Department of Neurosurgery, Intermountain Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Jordan Crevelt
- School of Nursing, University of Utah, Salt Lake City, Utah; and
| | - Nicholas Whipple
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Robert J. Bollo
- Department of Neurosurgery, Intermountain Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel Cheshier
- Department of Neurosurgery, Intermountain Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
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7
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Cler SJ, Skidmore A, Yahanda AT, Mackey K, Rubin JB, Cluster A, Perkins S, Gauvain K, King AA, Limbrick DD, McEvoy S, Park TS, Smyth MD, Mian AY, Chicoine MR, Dahiya S, Strahle JM. Genetic and histopathological associations with outcome in pediatric pilocytic astrocytoma. J Neurosurg Pediatr 2022; 29:504-512. [PMID: 35148515 DOI: 10.3171/2021.9.peds21405] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pilocytic astrocytomas (PAs) have a generally favorable prognosis; however, progression or recurrence after resection is possible. The prognostic value of histopathological qualifiers (defined below) or BRAF alterations is not well understood. The aim of this study was to identify the prognostic value of genetic and histopathological features of pediatric PAs. METHODS Patients treated for a WHO grade I PA at a single institution were analyzed for histopathological and genetic features and outcomes. "Histopathological qualifier" refers to designations such as "WHO grade I PA with increased proliferative index." BRAF alterations include gene fusions and point mutations. Patients with neurofibromatosis type 1 were excluded. RESULTS A total of 222 patients were analyzed (51% female, mean age 9.6 years). Tumors were located in the cerebellum/fourth ventricle (51%), optic pathway/hypothalamus (15%), brainstem (12%), and cerebral cortex (11%). BRAF alterations were screened for in 77 patients and identified in 56 (73%). Histopathological qualifiers were present in 27 patients (14%). Resection was performed in 197 patients (89%), 41 (21%) of whom displayed tumor progression or recurrence after resection. Tumor progression or recurrence was not associated with histopathologic qualifiers (p = 0.36) or BRAF alterations (p = 0.77). Ki-67 proliferative indices were not predictive of progression or recurrence (p = 0.94). BRAF alterations, specifically KIAA1549 fusions, were associated with cerebellar/fourth ventricular tumor location (p < 0.0001) and younger patient age (p = 0.03). Patients in whom gross-total resection was achieved had lower rates of progression and recurrence (p < 0.0001). CONCLUSIONS Histopathological features/qualifiers and BRAF alterations were not associated with tumor recurrence/progression in pediatric PAs. The extent of resection was the only factor analyzed that predicted outcome.
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Affiliation(s)
- Samuel J Cler
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander Skidmore
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Joshua B Rubin
- 3Department of Neuroscience, Washington University School of Medicine, St. Louis.,4Department of Pediatrics, Washington University School of Medicine, Division of Hematology and Oncology, St. Louis
| | - Andrew Cluster
- 4Department of Pediatrics, Washington University School of Medicine, Division of Hematology and Oncology, St. Louis
| | - Stephanie Perkins
- 4Department of Pediatrics, Washington University School of Medicine, Division of Hematology and Oncology, St. Louis.,5Department of Radiation Oncology, Washington University School of Medicine, St. Louis
| | - Karen Gauvain
- 4Department of Pediatrics, Washington University School of Medicine, Division of Hematology and Oncology, St. Louis
| | - Allison A King
- 4Department of Pediatrics, Washington University School of Medicine, Division of Hematology and Oncology, St. Louis
| | - David D Limbrick
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sean McEvoy
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ali Y Mian
- 6Department of Radiology, Washington University School of Medicine, St. Louis; and
| | - Michael R Chicoine
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sonika Dahiya
- 7Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer M Strahle
- 1Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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