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Khanafer A, Henkes H, Cohen J, Albiña-Palmarola P, Gomori JM, Forsting M, von Gottberg P. Endovascular treatment of distal anterior cerebral artery aneurysms using flow modulation devices: mid- and long-term results from a two-center study. Front Neurol 2024; 15:1368612. [PMID: 38529030 PMCID: PMC10962386 DOI: 10.3389/fneur.2024.1368612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/28/2024] [Indexed: 03/27/2024] Open
Abstract
Purpose Flow-diverter (FD) stents have become an established treatment for intracranial aneurysms in recent years, but their use for aneurysms in distal cerebral vessels with small carrier vessel diameters remains controversial. This study describes the method and mid- and long-term outcomes of FD treatment of distal anterior cerebral artery aneurysms (DACAAs) at two neurointerventional centers, to elucidate this topic and provide more in-depth data. Methods Data for all patients at two neurointerventional centers who were treated with FDs for DACAAs in the pericallosal and supracallosal segment of the anterior cerebral artery were retrospectively analyzed. Data on periprocedural complications, and short-, mid- and long-term follow-up findings were recorded. Results Forty-one patients were eligible for inclusion in the study. Three FD models were used, one of which had an anti-thrombotic coating. Two periprocedural complications (5%) occurred but did not cause a change in the mRS. In the long-term follow-up, at 29 months and beyond, 83% of assessable patients showed complete occlusion of the aneurysms without new neurological deficits. Conclusion FDs are a safe and effective treatment approach for DACAAs. This study indicated a low risk of complications, and high closure rates in short-, mid- and long-term follow-up.
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Affiliation(s)
- Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Pablo Albiña-Palmarola
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
| | - John Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Forsting
- Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany
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Zhu X, He Z, Wu Z, Li Y, Zhao Y, Wang B, Zhang N, Huang Q, Yang T, Yang M, Li J, Yang X, Wang Y, Zhang Z. Treatment and outcome analysis of patients with ruptured distal anterior cerebral artery aneurysms: a multicenter real-world study. Front Neurol 2024; 15:1329142. [PMID: 38469588 PMCID: PMC10925688 DOI: 10.3389/fneur.2024.1329142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/12/2024] [Indexed: 03/13/2024] Open
Abstract
Objective To reveal the safety and efficacy of clipping and coiling in patients with ruptured distal anterior cerebral artery aneurysms (DACAA) and to calculate the risk factors affecting the two-year survival rate in follow-up patients. Methods A retrospective study was conducted on the data of 140 patients (21 were lost to follow-up) with DACAA rupture who were treated by neurosurgery at 12 medical centers over a 2-year period, from January 2017 to December 2020. Univariate analysis was used to examine factors contributing to poor patient prognosis and to compare the prognosis of coiling and clipping treatments. Survival analysis was employed to compare survival rates between coiling and clipping, and risk factors affecting patient survival were analyzed using multivariate Cox regression analysis. Results Out of 140 patients with ruptured DACAA, 80 (57.1%) were male, and 60 (42.9%) were female. A total of 111 (79.3%) patients were classified under Hunt-Hess scale grades I-III, while 95 (67.9%) were graded I-III according to the WFNs classification. Among them, 63 (45%) were treated with clipping, and 77 (55%) underwent coiling. Within 2 years of discharge from the hospital, 31 (59.6%) patients who underwent clipping and 54 (80.6%) who underwent coiling had a good prognosis. Multivariate Cox regression analysis revealed that only WFNs classification (I-III) was a protective factor influencing the 2-year survival of patients with ruptured DACAA. Conclusion In the reality of medical practice, neurosurgeons are more likely to choose clipping as the treatment for cases with WFNs classification than or equal to III. There was no difference between clipping and coiling in the two-year prognosis at discharge. High priority should be given to DACAA cases with WFNs grading (I-III), as better outcomes can be achieved. The sample size will continue to be enlarged in the future to obtain more accurate findings. Abstracts for reviews, technical notes, and historical vignettes do not need to be separated into sections. They should begin with a clear statement of the paper's purpose followed by appropriate details that support the authors' conclusion(s).
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Affiliation(s)
- Xiaowei Zhu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Yangquan First People's Hospital, Yangquan, Shanxi, China
| | - Zhen He
- Department of Neurosurgery, People's Hospital of Zunhua, Zunhua, Hebei, China
| | - Zhuolin Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yang Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangyue Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Nai Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Tao Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Minghao Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jia Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yanzhou Wang
- Department of Neurosurgery, Cangzhou Central Hospital of Hebei, Cangzhou, Hebei, China
| | - Zhongyuan Zhang
- Department of Neurosurgery, People's Hospital of Zunhua, Zunhua, Hebei, China
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Sharma GR, Karki P, Joshi S, Paudel P, Shah DB, Baburam P, Bidhan G. Factors Affecting the Outcome after Surgical Clipping of Ruptured Distal Anterior Cerebral Artery (DACA) Aneurysms. Asian J Neurosurg 2023; 18:557-566. [PMID: 38152539 PMCID: PMC10749838 DOI: 10.1055/s-0043-1771371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Objective The purpose of this study is to assess demographic, clinical, and unique morphological characteristics of distal anterior cerebral artery (DACA) aneurysm. The relation of outcome included Glasgow Outcome Scale (GOS) using various independent variables, Hunt and Hess clinical grade (H&H), Miller Fischer grade, intraoperative rupture, and comparison of outcomes at discharge and last follow-up. Methods Demographic data, aneurysm characteristics, and treatment outcomes were evaluated in 28 ruptured DACA aneurysms operated over a period of 13 years. Association between independent variables and dependent variables (GOS) at discharge and at last follow-up (13 years) was analyzed, and the interrelationship between these factors and outcome was evaluated. GOS was used to assess functional outcomes. Results Over a period of 13 years, 500 patients harboring ruptured intracranial aneurysms were surgically clipped, and out of them 28 patients (5.6%) had ruptured DACA aneurysms. In this series, 20 (71.4%) patients had low grade and 8 (28.6%) had high grade H&H. Out of the 28 patients, 19 (67.8%) had good recovery, 6 (21.5%) were severely disabled, and 3 (10.7%) died at the time of discharge. On the last follow-up (13 years), smoking ( p -value 0.03) and use of temporary clip ( p -value 0.00) were significant predictors for unfavorable outcome. Conclusion The results of our case series show that even with ruptured aneurysm excellent overall outcome after microsurgical clipping can be achieved, even though among cerebral aneurysms, DACA aneurysm is considered to have less favorable outcome. Alcohol consumption and use of temporary clip were the predictors for unfavorable outcome at the time of discharge. On the last follow-up, smoking and use of temporary clip were found to be the risk factors for unfavorable outcome. Although the small sample size of this study is a limitation, smoking and use of temporary clip play an important role on the overall outcome. The aim of this study was to analyze data to determine factors which may influence outcome after surgical clipping of ruptured DACA aneurysms.
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Affiliation(s)
| | - Prasanna Karki
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Prakash Paudel
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | | | - Pokharel Baburam
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
| | - Gyawali Bidhan
- Department of Neurosciences, Nepal Mediciti Hospital, Lalitpur, Nepal
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Menon G, Srinivasan S, Pai A, Hegde A. Mini anterior interhemispheric approach for A3 segment distal anterior cerebral artery aneurysms. Clin Neurol Neurosurg 2023; 226:107598. [PMID: 36706678 DOI: 10.1016/j.clineuro.2023.107598] [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: 11/21/2022] [Revised: 12/28/2022] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Aneurysms of the A3 segment of the distal anterior cerebral artery (DACA), in relation to the genu of the corpus callosum, are specific sub-group which pose unique surgical challenges due to their discrete anatomical location. We describe a mini-anterior interhemispheric approach which can be safely utilised to clip these aneurysms rather than the traditional bifrontal approach. METHODS Retrospective analysis of the clinical and radiological data of ruptured DACA-A3 aneurysms operated between 2014 and 2021 at our institute. A curvilinear scalp incision within the hairline followed by raising small, unilateral, free frontal bone flap, avoiding the opening of frontal sinus. Superior sagittal sinus is displaced medially, inter-hemispheric dissection carried out with posterior trajectory and small callosotomy is performed. DACA is skeletonised, proximal control is established, and the A3 aneurysm is dissected and clipped. RESULT Our cohort of 18 patients had a definite female preponderance (F:M::2:1) with mean age of 55.6 years. On admission three patients were categorized as WFNS Grade I, thirteen in Grade II, and two in Grade III for subarachnoid haemorrhage. All the patients had evidence of blood in the interhemispheric fissure; intraparenchymal haemorrhage was seen in seven, with intraventricular haemorrhage in six patients. Within the A3 segment six aneurysms were infragenu (inferior), eight were at the genu (anterior) and four were supragenu (superior). Two (11.1%) elderly patients succumbed post-surgery following ischemic infarcts and associated complications. At the time of follow-up at 3 months of the remaining sixteen (72.2%) patients, thirteen had a good outcome (mRS 0-3) and three (16.7%) had a poor outcome (mRS > 3). CONCLUSION The mini anterior interhemispheric is an effective minimally invasive alternative for A3 segments aneurysms and helps to avoid the complications of the conventional bifrontal interhemispheric approach.
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Affiliation(s)
- Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India
| | - Siddharth Srinivasan
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India
| | - Ashwin Pai
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher education, Manipal, India.
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Rios-Zermeno J, Tovar-Romero LA, Cano-Velazquez G, Marian-Magana R, Sangrador-Deitos M, Gomez-Amador JL. De-novo formation of neighboring intracranial aneurysm after spontaneous thrombosis of a ruptured distal anterior cerebral artery aneurysm: A case report and review of the literature. J Cerebrovasc Endovasc Neurosurg 2022; 25:347-351. [PMID: 36592985 DOI: 10.7461/jcen.2023.e2022.07.006] [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: 07/11/2022] [Accepted: 11/29/2022] [Indexed: 01/04/2023] Open
Abstract
Intracranial aneurysms arise in 1-2% of the population and usually present as hemorrhagic strokes. Spontaneous thrombosis of a ruptured intracranial aneurysm occurs in 1-3% and most commonly in giant aneurysms, with complete thrombosis in just 13-20% of the cases. Thrombosis of smaller aneurysms is rare. Here we present a case of a patient who presented with a ruptured intracranial aneurysm that subsequently thrombosed, discovering a neighboring de-novo aneurysm during follow-up. We hypothesized that after thrombosis, the hemodynamic characteristics that contributed to the formation of the first aneurysm were replicated.
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Affiliation(s)
- Jorge Rios-Zermeno
- Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Gerardo Cano-Velazquez
- Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Ricardo Marian-Magana
- Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Marcos Sangrador-Deitos
- Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Juan Luis Gomez-Amador
- Department of Neurological Surgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Imada Y, Mihara C. A Simple Method to Estimate the Trajectory to the Genu of the Corpus Callosum in the Interhemispheric Approach for Distal Anterior Cerebral Artery Aneurysms. Neurol Med Chir (Tokyo) 2021; 62:140-148. [PMID: 34880164 PMCID: PMC8918368 DOI: 10.2176/nmc.tn.2021-0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In the interhemispheric approach (IHA) for the distal anterior cerebral artery (DACA) aneurysms, the surgical trajectory to a DACA aneurysm is very important because surgeons sometimes encounter the intraoperative disorientation and the premature rupture. The purpose of this study was to clarify the anatomical landmarks indicating the trajectory to the genu of the corpus callosum (GCC) at the early stage of dissection for the correct intraoperative orientation. “Point A” was defined as the crossing point between the frontal bone and the line connecting the projected external acoustic opening (EAO) and the GCC on the midline slice of the sagittal three-dimensional computed tomography angiography (3D-CTA) images. We measured the distance from the nasion to Point A using midline sagittal slice images from 50 patients who underwent 3D-CTA at our institution. The average distance was 7.0 cm (±0.3 cm). Therefore, the direction of the spatula inserted in the direction of the EAO from Point A (7 cm above the nasion) corresponds to the trajectory to the GCC. In DACA aneurysms of the A3 segment, the pericallosal artery distal to the aneurysm can be safely identified by dissecting the interhemispheric fissure distal to the trajectory to the GCC. In DACA aneurysms of the A4 or A5 segment, the parent artery of the aneurysm can be safely identified by dissection along the trajectory to the GCC. Point A and the EAO can be used as landmarks indicating the trajectory to the GCC for the correct intraoperative orientation in the IHA for DACA aneurysms.
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Affiliation(s)
| | - Chie Mihara
- Department of Neurosurgery, Yamada Memorial Hospital
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Deuschl C, Darkwah Oppong M, Styczen H, Markhardt L, Wrede K, Jabbarli R, Sure U, Radbruch A, Forsting M, Wanke I, Mönninghoff C. Therapy results of pericallosal aneurysms: A retrospective unicenter study. Clin Pract 2020; 10:1257. [PMID: 33014320 PMCID: PMC7512184 DOI: 10.4081/cp.2020.1257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/30/2020] [Indexed: 12/27/2022] Open
Abstract
This retrospective study aims to compare treatment results of ruptured and unruptured pericallosal artery aneurysms (PAAs) regarding patient outcome and aneurysm recurrence after endovascular treatment (EVT) and neurosurgical treatment (NT). A total of 67 patients with PAA were admitted to our hospital, 44 patients with subarachnoidal hemorrhage (SAH) due to a ruptured PAA and 23 patients with unruptured PAA. The radiographic features of PAA were collected from pre-treatment digital subtraction angiography. In addition, demographic, clinical and radiographic parameters of all patients were recorded. Outcome was measured based on the modified Rankin scale (mRS) at 6 months after admission (favorable mRS score, 0-2 vs unfavorable mRS score, 3-6). Overall 46 patients underwent EVT and 21 patients NT. Six months after discharge 24 patients with SAH had a favorable outcome (mRS 0-2) and 16 patients an unfavorable outcome (mRS 3-6). Mortality rate of patients with SAH was 9.1% (4/44). Overall aneurysm recurrence was treated in 13 % of patients in the EVT cohort (6/46), whereas patients treated with NT had no recurrence. All patients with unruptured PAA had a favorable outcome. EVT and NT of PAA show comparable good results, although aneurysm recurrence occurs more often after EVT.
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Affiliation(s)
- Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Lisa Markhardt
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Karsten Wrede
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Alexander Radbruch
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Isabel Wanke
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
- Center for Neuroradiology, Clinic Hirslanden, Zurich, Switzerland
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
- Clinic for Neuroradiology, Clemenshospital Muenster, Germany
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Gandhi S, Cavallo C, Zhao X, Belykh E, Lee M, Yoon S, Labib MA, Meybodi AT, Moreira LB, Preul MC, Nakaji P. Minimally invasive approaches to aneurysms of the anterior circulation: selection criteria and clinical outcomes. J Neurosurg Sci 2018; 62:636-649. [PMID: 30207433 DOI: 10.23736/s0390-5616.18.04562-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last few decades, cerebrovascular surgery has gravitated towards a minimally invasive philosophy without compromising the foundational principles of patient safety and surgical efficacy. Enhanced radiosurveillance modalities and increased average life expectancy have resulted in an increased reported incidence of intracranial aneurysms. Although endovascular therapies have gained popularity in the recent years, microsurgical clipping continues to be of value in the management of these aneurysms owing to its superior occlusion rates, applicability to complex aneurysms and reduced retreatment rates. The concept of keyhole transcranial procedures has advanced the field significantly leading to decreased postoperative neurological morbidity and quicker recovery. The main keyhole neurosurgical approaches include the supraorbital craniotomy (SOC), lateral supraorbital craniotomy (LSOC), mini-pterional craniotomy (MPTC), mini-orbitozygomatic craniotomy and the mini anterior interhemispheric approach (MAIA). As these minimally invasive approaches can have an inherent limitation of a narrow viewing angle and low regional illumination, the use of endoscopic assistance in such procedures is being popularized. Neuroendoscopy can aid in the visualization of hidden neurovascular structures and inspection of the parent arterial segment without undue retraction of the lesion. This review focuses on the historical progression of the surgical management of intracranial aneurysms, the technical details of various minimally invasive approaches, patient selection and clinical outcomes of the anterior circulation aneurysms and useful tenets to avoid complications during these procedures. Meticulous preoperative planning to understand the patient's vascular anatomy, the orientation and relationship of the aneurysm to adjacent structures, use of neuronavigation guidance and endoscopic assistance if needed can lead to an optimal surgical outcome while minimizing neurological morbidity and mortality.
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Affiliation(s)
- Sirin Gandhi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Claudio Cavallo
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Xiaochun Zhao
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Evgenii Belykh
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Michaela Lee
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Seungwon Yoon
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mohamed A Labib
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Ali T Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Leandro B Moreira
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mark C Preul
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Peter Nakaji
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA -
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