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Montasr MM, Fotakopoulos G, Georgakopoulou VE, Fotakopoulou O, Trakas N, Sklapani P, Fountas KN. Association between polymorphisms of DNA repair genes and intracranial aneurysms: A systematic review and meta‑analysis. MEDICINE INTERNATIONAL 2024; 4:59. [PMID: 39092011 PMCID: PMC11289859 DOI: 10.3892/mi.2024.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Abstract
Intracranial aneurysms (IAs) are present in ~2% of the general population, and genetic factors cannot be excluded for the risk of their development. The gene factors that result in the changes in the vascular extracellular matrix (ECM) may also be a key reason for IAs being hereditary. The VCAN gene [also known as chondroitin sulfate proteoglycan 2 (CSPG2)] plays various roles in maintaining ECM functions. The present systematic review and meta-analysis aimed to investigate all eligible articles involving IAs on the association with germ line SNPs of DNA repair genes (up to January, 2024). The total number of patients was 2,308 [987 cases (poor outcomes) and 1,321 controls (good outcomes)]. The results revealed that rs2287926 G/G genotype and G allele and rs251124 T/T genotype and minor allele T increased the risk of developing IAs. However, further studies are required to examine these gene polymorphisms as screening markers for IAs.
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Affiliation(s)
- Mohamed M. Montasr
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Ourania Fotakopoulou
- Department of Pediatrics, General Hospital of Zakynthos ‘Agios Dionysios’, 29100 Zakynthos, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Kostas N. Fountas
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Miyama M, Matsukawa H, Sakakibara F, Uchida K, Shirakawa M, Yoshimura S. Perioperative Antiplatelet Management in the Flow-Diverter Treatment for Unruptured Cerebral Aneurysms: A Single-Center, Retrospective Analysis. World Neurosurg 2024; 183:e44-e50. [PMID: 37918564 DOI: 10.1016/j.wneu.2023.10.128] [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: 10/16/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Although periprocedural antiplatelet therapy for the treatment of unruptured intracranial aneurysms (UIAs) using flow-diverter stents (FDSs) is necessary to avoid thromboembolic complications, a definite antiplatelet therapy has not been established. We aimed to evaluate the safety and efficacy of periprocedural antiplatelet management in UIA treatment with FDS. METHODS A single-center retrospective analysis of consecutive patients with UIAs treated with FDSs between September 2013 and January 2022 was conducted. Patients received dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) for 14-day before and 3-6 months after FDS placement. Platelet aggregation was evaluated prior to treatment using light transmission aggregometry, which was classified into 3 grades; 1-3: promoted, 4-6: appropriate, and 7-9: non-responder, for adenosine diphosphate (ADP) and collagen. By this classification, the antiplatelet regimen was modified. Outcome included hemorrhagic and ischemic events. RESULTS 193 patients with 200 UIAs underwent 213 FDSs placement. The median platelet aggregability grade before treatment was 5 for ADP and 4 for collagen. Antiplatelet therapy modification was performed in 62 patients (32.1%). The median postoperative DAPT duration was 94 days. Antiplatelet medicine-related hemorrhagic events occurred in 4 patients (2.1%) and ischemic events occurred in 6 patients (3.1%). These patients had no morbido-mortality. CONCLUSIONS Periprocedural antiplatelet management based on the value of platelet aggregability was relatively safe and effective for treating UIA with FDS.
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Affiliation(s)
- Masataka Miyama
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Takarazuka City Hospital, Takarazuka, Hyogo, Japan
| | - Fumihiro Sakakibara
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan.
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Miller TR, Khunte M, Caffes N, Anders M, Rock P, Beitelshees AL, Malhotra A, Cannarsa G, Cherian J, Simard JM, Jindal G, Gandhi D. Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2022:neurintsurg-2022-018858. [PMID: 35728944 DOI: 10.1136/neurintsurg-2022-018858] [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: 03/02/2022] [Accepted: 05/28/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND High levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors. METHODS All successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60-235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRU<60 within 8 weeks of treatment was noted. Multivariable logistic regression was performed to determined independent predictors of the phenomenon. RESULTS Some 190 treatments were performed in 178 qualifying patients. A post-procedure PRU <60 occurred following 79% of treatments, documented on average after 8.5 (range 1-47) days. A higher procedure day hematocrit level (P=0.003, OR 1.09, 95% CI 1.029 to 1.152) was an independent predictor of reaching a PRU <60, while intra-procedural midazolam exposure (P=0.044, OR 0.44, 95% CI 0.201 to 0.980) and a higher procedure-day PRU (P=0.047, OR 0.99, 95% CI 0.982 to 1.000) were associated with a reduced odds. Time-since-procedure and hematocrit levels were associated with excessive platelet inhibition when excluding patients who initially demonstrated hyperresponse. CONCLUSION Elevations in platelet inhibition were frequently observed following flow diversion with Pipeline.
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Affiliation(s)
- Timothy R Miller
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicholas Caffes
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Megan Anders
- Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Peter Rock
- Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Amber L Beitelshees
- Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gregory Cannarsa
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacob Cherian
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - J Marc Simard
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gaurav Jindal
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Dheeraj Gandhi
- Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Feigen CM, Vivanco-Suarez J, Javed K, Dardick JM, Holland R, Mendez-Ruiz A, Ortega-Gutierrez S, Haranhalli N, Altschul DJ. Pipeline Embolization Device and Pipeline Flex Versus Surpass Streamline Flow Diversion in Intracranial Aneurysms: A Retrospective Propensity Score-Matched Study. World Neurosurg 2022; 161:e384-e394. [PMID: 35151920 DOI: 10.1016/j.wneu.2022.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare safety and efficacy profiles in aneurysms treated with Pipeline Embolization Device or Pipeline Flex versus Surpass Streamline flow diverters (FDs). METHODS Patients who underwent flow diversion for aneurysm treatment at 2 centers were included. Covariates comprised patient demographics, comorbidities, and aneurysm characteristics. Metrics included number of devices, adjuvant device use, case duration, and radiation exposure. Outcomes included periprocedural complications and radiographic results at follow-up. Propensity score-matched pairs were generated using demographic and aneurysm characteristics to verify the outcomes in equally sized groups. RESULTS The majority of 141 flow diversion procedures performed on 126 patients were in the anterior circulation (96%) and unruptured (93%). Operators experienced more complications placing Surpass FDs compared with Pipelines (18.2% vs. 3.1%, P = 0.005) but used fewer Surpass devices per case (1 device in all Surpass cases and range for Pipeline cases 1-7; P < 0.001). Ballooning was more frequent for Surpass (29.5% vs. 2.1%, P < 0.001). There were no differences in mortality (2.1% vs. 0, P = 1.00), intracranial hemorrhage (3.1% vs. 0, P = 0.551), or stroke (4.2% vs. 6.8%, P = 0.680). Rates of aneurysm obliteration at follow-up were similar. Propensity-matched pairs had no differences in FD deployment complications or perioperative events, yet the significant differences remained for adjuvant balloon use and number of FDs deployed. CONCLUSIONS While the devices demonstrated similar safety and efficacy profiles, deployment of the Surpass Streamline was more technically challenging than Pipeline Embolization Device or Pipeline Flex. Prospective cohort studies are needed to corroborate these findings.
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Affiliation(s)
- Chaim M Feigen
- Montefiore Department of Neurological Surgery, Bronx, New York, USA.
| | - Juan Vivanco-Suarez
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kainaat Javed
- Montefiore Department of Neurological Surgery, Bronx, New York, USA
| | - Joseph M Dardick
- Montefiore Department of Neurological Surgery, Bronx, New York, USA
| | - Ryan Holland
- Montefiore Department of Neurological Surgery, Bronx, New York, USA
| | - Alan Mendez-Ruiz
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Neil Haranhalli
- Montefiore Department of Neurological Surgery, Bronx, New York, USA
| | - David J Altschul
- Montefiore Department of Neurological Surgery, Bronx, New York, USA
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Hong Q, Li W, Ma J, Jiang P, Zhang Y. Endovascular treatment of vertebral and basilar artery aneurysms with low-profile visualized intraluminal support device. BMC Neurol 2021; 21:198. [PMID: 33992093 PMCID: PMC8122564 DOI: 10.1186/s12883-021-02180-1] [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: 08/01/2020] [Accepted: 04/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background The Low-profile Visualized Intraluminal Support (LVIS) device is a self-expanding, nitinol, single-braid, closed-cell device that was recently developed for endovascular embolization of intracranial aneurysms. However, current knowledge regarding the use of LVIS devices to treat vertebral and basilar artery aneurysms is limited. We aimed to evaluate the feasibility, efficacy, and safety of the LVIS device for treating vertebral and basilar artery aneurysms. Methods Between January 2015 and December 2017, patients with vertebral and basilar artery aneurysms treated using LVIS stents were enrolled in this study. We analyzed patients’ demographic, clinical and aneurysmal characteristics, procedural details, complications, and angiographic and clinical follow-up results. Results We identified 63 patients with 64 vertebral and basilar artery aneurysms who underwent treatment with (n = 59) or without (n = 5) LVIS stenting, including 10 patients with ruptured aneurysms. Forty-one aneurysms were located at the vertebral artery, and 23 at the basilar artery. Intraprocedural-related complications developed in three (4.8%) patients, while none of these patients developed morbidities or died during follow-up. Three patients developed post-procedural complications (4.8%). Two patients experienced ischemic events immediately post-procedure. A minor permanent morbidity developed in one of the two patients (1.6%). The mortality rate was 1.6%, for that the patient died of brainstem hemorrhage after 1 month of follow-up. At a mean follow-up of 12.5 months, 39/43 (90.7%) patients had stable or improved aneurysms, and four (9.3%) had recanalized. Conclusions LVIS device of vertebral and basilar artery aneurysms may be an acceptable safety profile and may represent a reasonable treatment option in the short-term. Long-term and larger cohort studies are necessary to validate our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02180-1.
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Affiliation(s)
- Quanlong Hong
- Department of Neurology, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, NansanhuanXilu 119, Fengtai District, Beijing, 100070, China.,Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jing Ma
- Department of Echocardiography, Shanghai Xuhui Central Hospital, Zhongshan-Xuhui Hospital, Fudan University, Shanghai, China
| | - Peng Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, NansanhuanXilu 119, Fengtai District, Beijing, 100070, China.
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, NansanhuanXilu 119, Fengtai District, Beijing, 100070, China.
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Charbonnier G, Desilles JP, Escalard S, Maier B, Ciccio G, Smajda S, Fahed R, Delvoye F, Redjem H, Blanc R, Piotin M, Mazighi M. Timing and Spectrum of Neurological Complications After Flow Diverter Implantation for Intracranial Aneurysms. Front Neurol 2021; 12:590383. [PMID: 33959085 PMCID: PMC8093792 DOI: 10.3389/fneur.2021.590383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 03/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose: The aim of this study was to characterize neurological complications after flow diverter (FD) treatment on a long follow-up cohort and identify predictive factors associated with these complications. Methods: This study was conducted on a monocentric cohort of patients treated for intracranial aneurysms by FD. Results: Between September 2008 and July 2018, 413 patients were treated for 514 aneurysms: 18% of the patients presented with at least one neurological complication during a median follow-up of 446 days (IQR 186–1,210). Sixty-one patients presented with ischemic complications, 13 with hemorrhagic ones and 10 with compressive processes. Among 89 neurological complications 64.5% were peri-operative (occurring within the 30 days following the procedure) and 35.5% were delayed after 1 month. Conclusions: Overall, neurological complications after FD implantation were overrepresented by cerebrovascular ischemic events occurring during the peri-operative period, but also in a delayed manner after 1 year. Long-term follow-up is relevant after aneurysm intervention using FD.
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Affiliation(s)
| | | | - Simon Escalard
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Benjamin Maier
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Gabriele Ciccio
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Stanislas Smajda
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Robert Fahed
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - François Delvoye
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Hocine Redjem
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Raphaël Blanc
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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7
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Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience. Neuroradiology 2020; 62:1029-1041. [PMID: 32170373 DOI: 10.1007/s00234-020-02387-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents. METHODS From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups. RESULTS Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024). CONCLUSION In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.
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Sweid A, Starke RM, Herial N, Chalouhi N, Das S, Baldassari MP, Alexander TD, Tjoumakaris S, Gooch MR, Hasan D, Rosenwasser RH, Romo V, Jabbour P. Predictors of Complications, Functional Outcome, and Morbidity in a Large Cohort Treated With Flow Diversion. Neurosurgery 2019; 87:730-743. [DOI: 10.1093/neuros/nyz508] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/20/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
A dramatic improvement in obliteration rates of large, wide-necked aneurysms has been observed after the FDA approved the Pipeline Embolization Device (PED) in 2011.
OBJECTIVE
To assess the predictors of complications, morbidity, and unfavorable outcomes in a large cohort of patients with aneurysms treated with PED.
METHODS
A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010 to 2019.
RESULTS
A total of 598 aneurysms were treated during a period extending from 2010 to 2019 (84.28% females, mean age 55.5 yr, average aneurysm size 8.49 mm). Morbidity occurred at a rate of 5.8% and mortality at a rate of 2.2%. Ischemic stroke occurred at a rate of 3%, delayed aneurysmal rupture (DAR) at 1.2%, and distal intraparenchymal hemorrhage (DIPH) at 1.5%. On multivariate analysis, the predictor of stroke was aneurysm size >15 mm. Predictors of DAR were previous subarachnoid hemorrhage (SAH), increasing aneurysm size, and posterior circulation aneurysm. Predictors of DIPH were using more than 1 PED and baseline P2Y12 value. Predictors of in-stent stenosis were the increasing year of treatment and balloon angioplasty, whereas increasing age and previous treatment were negatively associated with in-stent stenosis. Predictors of morbidity were posterior circulation aneurysms, increasing aneurysm size, and hypertension, and incidental aneurysm diagnosis was protective for morbidity.
CONCLUSION
Flow diversion is a safe and effective treatment option for aneurysms. A better understanding of predictive factors of complications, morbidity, and functional outcomes is of high importance for a more accurate risk assessment.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Hospital, Miami, Florida
| | - Nabeel Herial
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Somnath Das
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael P Baldassari
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Tyler D Alexander
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - M Reid Gooch
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | - Robert H Rosenwasser
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Victor Romo
- Department of Anesthesia, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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