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Rennert RC, Brandel MG, Budohoski KP, Twitchell S, Fredrickson VL, Grandhi R, Couldwell WT. Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2023; 24:610-618. [PMID: 36786755 DOI: 10.1227/ons.0000000000000618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/05/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined). OBJECTIVE To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization. METHODS This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades. RESULTS Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade ( P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades ( P < .05). Tmax >4-second volume inversely predicted indirect bypass patency. CONCLUSION Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.
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Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael G Brandel
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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2
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Nguyen VN, Motiwala M, Parikh K, Miller LE, Barats M, Nickele CM, Inoa V, Elijovich L, Goyal N, Hoit DA, Arthur AS, Morcos JJ, Khan NR. Extracranial-Intracranial Cerebral Revascularization for Atherosclerotic Vessel Occlusion: An Updated Systematic Review of the Literature. World Neurosurg 2023; 173:199-207.e8. [PMID: 36758795 DOI: 10.1016/j.wneu.2023.02.003] [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: 12/22/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era. METHODS Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales. RESULTS A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio [OR], 0.65 [0.48-0.87]; P = 0.004), long-term ischemia (OR, 0.32 [0.23-0.44]; P < 0.0001), overall ischemia (OR, 0.36 [0.28-0.44]; P < 0.0001), and favorable outcomes (OR, 3.63 [2.84-4.64]; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS. CONCLUSIONS Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.
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Affiliation(s)
- Vincent N Nguyen
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Kara Parikh
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - L Erin Miller
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Michael Barats
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Christopher M Nickele
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Violiza Inoa
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Lucas Elijovich
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Nitin Goyal
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Daniel A Hoit
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Adam S Arthur
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Jacques J Morcos
- University of Miami Department of Neurosurgery, Miami, Florida, USA
| | - Nickalus R Khan
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA.
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3
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Abdelgadir J, Haskell-Mendoza AP, Magno AR, Suarez AD, Antwi P, Raghavan A, Nelson P, Yang LZ, Jung SH, Zomorodi AR. Revisiting flow augmentation bypass for cerebrovascular atherosclerotic vaso-occlusive disease: Single-surgeon series and review of the literature. PLoS One 2023; 18:e0285982. [PMID: 37205640 DOI: 10.1371/journal.pone.0285982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/07/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Despite advances in the nonsurgical management of cerebrovascular atherosclerotic steno-occlusive disease, approximately 15-20% of patients remain at high risk for recurrent ischemia. The benefit of revascularization with flow augmentation bypass has been demonstrated in studies of Moyamoya vasculopathy. Unfortunately, there are mixed results for the use of flow augmentation in atherosclerotic cerebrovascular disease. We conducted a study to examine the efficacy and long term outcomes of superficial temporal artery to middle cerebral artery (STA-MCA) bypass in patients with recurrent ischemia despite optimal medical management. METHODS A single-institution retrospective review of patients receiving flow augmentation bypass from 2013-2021 was conducted. Patients with non-Moyamoya vaso-occlusive disease (VOD) who had continued ischemic symptoms or strokes despite best medical management were included. The primary outcome was time to post-operative stroke. Time from cerebrovascular accident to surgery, complications, imaging results, and modified Rankin Scale (mRS) scores were aggregated. RESULTS Twenty patients met inclusion criteria. The median time from cerebrovascular accident to surgery was 87 (28-105.0) days. Only one patient (5%) had a stroke at 66 days post-op. One (5%) patient had a post-operative scalp infection, while 3 (15%) developed post-operative seizures. All 20 (100%) bypasses remained patent at follow-up. The median mRS score at follow up was significantly improved from presentation from 2.5 (1-3) to 1 (0-2), P = .013. CONCLUSIONS For patients with high-risk non-Moyamoya VOD who have failed optimal medical therapy, contemporary approaches to flow augmentation with STA-MCA bypass may prevent future ischemic events with a low complication rate.
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Affiliation(s)
- Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Aden P Haskell-Mendoza
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Amanda R Magno
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander D Suarez
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Prince Antwi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alankrita Raghavan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Patricia Nelson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Lexie Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
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Nguyen VN, Parikh KA, Miller LE, Motiwala M, Barats M, Goyal N, Arthur AS, Hoit DA, Khan NR. Double-Barrel (2-Donor-2-Recipient) Bypass as Rescue Treatment for Patient with Occluded Middle Cerebral Artery Intracranial Stent and Recurrent Ischemia. World Neurosurg 2022; 167:127-128. [PMID: 36096384 DOI: 10.1016/j.wneu.2022.08.150] [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: 07/03/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022]
Abstract
Stent occlusion is a challenging complication following endovascular interventions that require intracranial stenting.1-4 Although there are small series describing revascularization for stenoocclusive disease failing best medical management,5-14 there are few reports in the literature regarding surgical bypass as a treatment for stent occlusion.5 We present the case of a 37-year-old man who presented with right-sided weakness, numbness, and difficulty with speech and ambulation. His history is notable for a left M1 (segment of middle cerebral artery) occlusion 6 months prior that was treated with mechanical thrombectomy requiring repeat thrombectomy and rescue acute middle cerebral artery (MCA) stent placement given vessel reocclusion. Diagnostic cerebral angiography demonstrated stent occlusion. Given his continued ischemic symptoms despite best medical management, the patient underwent a double-barrel superficial temporal artery-MCA direct bypass to revascularize the MCA territory. To our knowledge, there is no literature to date describing a 2-donor-2-recipient direct bypass for the rescue treatment of symptomatic intracranial stent occlusion with recurrent ischemia. We review the case presentation, angiographic findings, surgical nuances, and postoperative course with imaging. The patient provided informed consent for the procedure and verbal support for publishing his image and inclusion in this submission.
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Affiliation(s)
- Vincent N Nguyen
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kara A Parikh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - L Erin Miller
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael Barats
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - Daniel A Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA; Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA.
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5
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Kim NC, Raz E, Shapiro M, Riina HA, Nelson PK, Levine JP, Nossek E. Salvage Superficial Temporal Artery to Middle Cerebral Artery Direct Bypass Using an Interposition Graft for Failed EDAS in Moyamoya Disease. World Neurosurg 2022; 163:60-66. [DOI: 10.1016/j.wneu.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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Raper DMS, Rutledge WC, Winkler EA, Meisel K, Callen AL, Cooke DL, Abla AA. Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:1-7. [PMID: 32895706 DOI: 10.1093/ons/opaa276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/11/2020] [Indexed: 02/02/2023] Open
Abstract
Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Karl Meisel
- Department of Neurology, University of California, San Francisco, California
| | - Andrew L Callen
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
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7
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Haynes J, Kronenburg A, Raz E, Rostanski S, Yaghi S, Ishida K, Shapiro M, Nelson PK, Tanweer O, Langer DJ, Riina HA, Eichel R, Nossek E. Superficial Temporal Artery to Middle Cerebral Artery Cranial Bypass for Nonmoyamoya Steno-Occlusive Disease in Patients Who Failed Optimal Medical Treatment: A Case Series. Oper Neurosurg (Hagerstown) 2021; 20:444-455. [PMID: 33475724 DOI: 10.1093/ons/opaa458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the post-Carotid Occlusion Surgery Study (COSS) era, multiple reviews suggested subset groups of patients as potential candidates for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. Among them are patients with recurrent strokes despite optimal medical therapy. There is a paucity of data on the outcome of bypass in these specific patients. OBJECTIVE To examine the safety and efficacy of direct STA-MCA bypass in patients with nonmoyamoya, symptomatic steno-occlusive disease with impaired distal perfusion, who failed optimal medical management or endovascular treatment. METHODS A retrospective review was performed to identify patients with cerebrovascular steno-occlusive disease who underwent bypass after symptomatic recurrent or rapidly progressive strokes, despite optimal conservative or endovascular treatment. RESULTS A total of 8 patients (mean age 60 ± 6 yr) underwent direct or combined direct/indirect STA-MCA bypass between 2016 and 2019. All anastomoses were patent. One bypass carried slow flow. There were no procedure-related permanent deficits. One patient developed seizures which were controlled by medications. A total of 7 out of 8 patients were stable or improved clinically at last follow-up (mean 27.3 ± 13.8 mo) without recurrent strokes. One patient did not recover from their presenting stroke, experienced severe bilateral strokes 4 mo postoperatively, and subsequently expired. Modified Rankin Scale (mRS) improved in 6 patients (75%), remained stable in 1 patient (12.5%), and deteriorated in 1 (12.5%). Good long-term functional outcome was achieved in 5 patients (63%, mRS ≤ 2). CONCLUSION Patients with symptomatic, hypoperfused steno-occlusive disease who fail optimal medical or endovascular treatment may benefit from cerebral revascularization. Direct or combined STA-MCA bypass was safe and provided favorable outcomes in this small series.
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Affiliation(s)
- Joseph Haynes
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Annick Kronenburg
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eytan Raz
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Sara Rostanski
- Department of Neurology, NYU Langone Health, New York, New York
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, New York
| | - Koto Ishida
- Department of Neurology, NYU Langone Health, New York, New York
| | - Maksim Shapiro
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Peter Kim Nelson
- Department of Radiology, Section of Neurointerventional Radiology, NYU Langone Health, New York, New York
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York
| | - David J Langer
- Department of Neurosurgery, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, New York
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York
| | - Roni Eichel
- Department of Neurology, Shaare Zedek Medical Center, Affiliated Teaching Hospital of the Hebrew University Medical Faculty, Jerusalem, Israel
| | - Erez Nossek
- Department of Neurosurgery, NYU Langone Health, New York, New York
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8
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Bertolini G, Fratianni A, Giombelli E. Letter: Controversies and Advances in Adult Intracranial Bypass Surgery in 2020. Oper Neurosurg (Hagerstown) 2021; 20:E255-E256. [PMID: 33373443 DOI: 10.1093/ons/opaa433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/05/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Giacomo Bertolini
- Department of Neurologic Surgery Azienda Ospedaliero-Universitaria Parma, Italy.,Department of Biomedical and Neuromotor Sciences University of Bologna Bologna, Italy
| | - Alessia Fratianni
- Department of Neurologic Surgery Azienda Ospedaliero-Universitaria Parma, Italy
| | - Ermanno Giombelli
- Department of Neurologic Surgery Azienda Ospedaliero-Universitaria Parma, Italy
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