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Griffiths E, Jayamohan J, Budday S. A comparison of brain retraction mechanisms using finite element analysis and the effects of regionally heterogeneous material properties. Biomech Model Mechanobiol 2024; 23:793-808. [PMID: 38361082 DOI: 10.1007/s10237-023-01806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/14/2023] [Indexed: 02/17/2024]
Abstract
Finite element (FE) simulations of the brain undergoing neurosurgical procedures present us with the great opportunity to better investigate, understand, and optimize surgical techniques and equipment. FE models provide access to data such as the stress levels within the brain that would otherwise be inaccessible with the current medical technology. Brain retraction is often a dangerous but necessary part of neurosurgery, and current research focuses on minimizing trauma during the procedure. In this work, we present a simulation-based comparison of different types of retraction mechanisms. We focus on traditional spatulas and tubular retractors. Our results show that tubular retractors result in lower average predicted stresses, especially in the subcortical structures and corpus callosum. Additionally, we show that changing the location of retraction can greatly affect the predicted stress results. As the model predictions highly depend on the material model and parameters used for simulations, we also investigate the importance of using region-specific hyperelastic and viscoelastic material parameters when modelling a three-dimensional human brain during retraction. Our investigations demonstrate how FE simulations in neurosurgical techniques can provide insight to surgeons and medical device manufacturers. They emphasize how further work into this direction could greatly improve the management and prevention of injury during surgery. Additionally, we show the importance of modelling the human brain with region-dependent parameters in order to provide useful predictions for neurosurgical procedures.
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Affiliation(s)
- Emma Griffiths
- Department of Mechanical Engineering, Institute of Continuum Mechanics and Biomechanics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91058, Erlangen, Germany.
| | - Jayaratnam Jayamohan
- Department of Pediatric Neurosurgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Silvia Budday
- Department of Mechanical Engineering, Institute of Continuum Mechanics and Biomechanics, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91058, Erlangen, Germany
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2
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Kuwajima T, Beppu M, Yoshimura S. Minimally invasive craniotomy for putaminal hemorrhage using a tubular retractor: A technical note. Surg Neurol Int 2024; 15:183. [PMID: 38840616 PMCID: PMC11152540 DOI: 10.25259/sni_265_2024] [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] [Received: 04/07/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024] Open
Abstract
Background Minimally invasive endoscopic and stereotactic surgery have been established as surgical treatments for putaminal hemorrhage. However, facilities that do not have equipment for endoscopic or stereotactic surgery will likely have to perform conventional craniotomy. Using a tubular retractor, we were able to perform minimally invasive surgery, such as endoscopic surgery. Methods A craniotomy was performed for left putaminal hemorrhage after cerebral infarction treatment. A 3-4 cm craniotomy centered at Kocher's point was performed under general anesthesia. A 2 cm incision was made in the cortex, and a tubular retractor was inserted under a microscope. The hematoma was reached at a position 4-5 cm from the cortex. Results Thanks to the tubular retractor, it was relatively easy to observe the hematoma, and it was possible to remove it and confirm hemostasis without difficulty. Brain injury caused by the retractor insertion cavity was small, and no hemostasis was required. The surgery was completed by dura mater closure, bone flap fixation, and wound closure as per the standard. Most of the putaminal hemorrhage could be removed, and there was no rebleeding after the operation. The patient is still undergoing rehabilitation because of aphasia and muscle weakness. Manual Muscle Testing was at three points in the upper limb, and four points in the lower limb remained. Conclusion For putaminal hemorrhage, microscopic craniotomy was performed using a tubular retractor and an approach such as endoscopic surgery. Craniotomy, hematoma removal, and hemostasis operations are also considered to be minimally invasive surgeries.
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Affiliation(s)
- Takuto Kuwajima
- Department of Neurosurgery, Saiseikai Noe Hospital, Osaka, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mikiya Beppu
- Department of Neurosurgery, Saiseikai Noe Hospital, Osaka, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Gurses ME, Lu VM, Gecici NN, Shah KH, Gökalp E, Bashti M, Haider S, Komotar RJ. Utilizing tubular retractors in colloid cyst resection: A single surgeon experience. Surg Neurol Int 2024; 15:179. [PMID: 38840593 PMCID: PMC11152534 DOI: 10.25259/sni_231_2024] [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] [Received: 03/27/2024] [Accepted: 05/04/2024] [Indexed: 06/07/2024] Open
Abstract
Background Colloid cysts are intracranial lesions originating from abnormalities in the primitive neuroepithelium folding of the third ventricle. Various surgical approaches have been explored for the management of colloid cysts, each carrying its own set of advantages and limitations. Tubular retractors developed recently alleviate retraction pressure through radial distribution, potentially offering benefits for colloid cyst resection. This study aims to introduce and assess a modified microsurgical method utilizing the tubular retractor for addressing colloid cysts. Methods The study included a retrospective assessment of patients who had colloid cysts and who were treated between 2015 and 2023 by one experienced surgeon. The demographic, clinical, radiological, histological, and surgical data regarding these patients were evaluated. The patients were assessed using the colloid cyst risk score, indicating a risk for obstructive hydrocephalus. Results The minimally invasive microsurgical approach was successfully applied to all 22 identified patients. No postoperative surgical complications were reported. Gross total resection was achieved in 21 (95.5%) patients. The early complication rate was 22.7% (n = 5). There were no postoperative seizures, permanent neurological deficits, or venous injuries. The average hospital stay was 3 days. There was no evidence of recurrence at an average follow-up length of 25.9 months. Conclusion The transtubular approach is an effective, safe method for treating colloid cysts. It achieves complete cyst removal with minimal complications, offering the benefits of less invasiveness, improved visualization, and reduced tissue disruption, strengthening its role in colloid cyst surgery.
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Affiliation(s)
| | - Victor M. Lu
- Department of Neurosurgery, Miami University, Miami, United States
| | | | | | - Elif Gökalp
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Malek Bashti
- Department of Neurosurgery, Miami University, Miami, United States
| | - Sameah Haider
- Department of Neurosurgery, Miami University, Miami, United States
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Jaimovich SG, Takeuchi K, Testa VT, Okumura E, Jaimovich R, Cinalli G. Cylinder tumor surgery in pediatric low-grade gliomas. Childs Nerv Syst 2024:10.1007/s00381-024-06417-5. [PMID: 38644385 DOI: 10.1007/s00381-024-06417-5] [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: 04/07/2024] [Accepted: 04/15/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Periventricular pediatric low-grade gliomas (pLGG) present a surgical challenge due to their deep-seated location, accessibility, and relationship with the subcortical network connections. Minimally invasive parafascicular approaches with tubular brain retractors (port brain surgery) have emerged, in recent years, as an alternative to conventional microsurgical and endoscopic approaches for removal of periventricular tumors. OBJECTIVES To describe the minimally invasive approach with tubular brain retractors for periventricular pLGG, its technique, applications, safety, and efficacy. METHODS In this article, we describe the port brain surgery techniques for periventricular pLGG as performed in different centers, with different commercialized tubular retractor systems. Illustrative cases followed by a literature review are analyzed, with a detailed description of different approaches or techniques, comparing their advantages and disadvantages with contemporary microsurgical and endoscopic approaches. CONCLUSIONS The port brain surgery with micro-exoscopic vision and endoscopic assistance, for the treatment of deep-seated lesions such as periventricular pLGG, is an alternative for achieving a functionally safe-gross total or subtotal-tumor resection, obtaining adequate tissue for pathological examination. This technique could offer a new dimension for a less-invasive, safe, and effective access to deep-seated tumors, offering the possibility to lower morbidity in experienced hands.
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Affiliation(s)
- Sebastian Gaston Jaimovich
- Department of Neurosurgery, "Prof. Dr. Juan P. Garrahan" Pediatric Hospital, Buenos Aires, Argentina
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | | | - Eriko Okumura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Roberto Jaimovich
- Department of Neurosurgery, "Prof. Dr. Juan P. Garrahan" Pediatric Hospital, Buenos Aires, Argentina
- Department of Neurosurgery, FLENI, Buenos Aires, Argentina
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy.
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Deopujari C, Shroff K, Malineni S, Shaikh S, Mohanty C, Karmarkar V, Mittal A. Intraventricular Tumors: Surgical Considerations in Lateral and Third Ventricular Tumors. Adv Tech Stand Neurosurg 2024; 50:63-118. [PMID: 38592528 DOI: 10.1007/978-3-031-53578-9_3] [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] [Indexed: 04/10/2024]
Abstract
Management of lateral and third ventricular tumors has been a challenge for neurosurgeons. Advances in imaging and pathology have helped in a better understanding of the treatment options. Technical refinement of microsurgical technique and addition of endoscopy has enabled more radical excision of tumors, when indicated, and added more safety.A proper understanding of the pathology at various ages and treatment options is continuously evolving. Many pediatric tumors are amenable to conservative surgical methods with effective complementary treatments. However, radical surgery is required in many adults as the main treatment and for many benign tumors. Various intraventricular lesions encountered and their surgical management is reviewed here for their efficacy, safety, and outcome, encompassing changes in our practice over the last 20 years.
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Affiliation(s)
- Chandrashekhar Deopujari
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Krishna Shroff
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Suhas Malineni
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | | | - Chandan Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Vikram Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Amol Mittal
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Roca E, Ramorino G. Brain retraction injury: systematic literature review. Neurosurg Rev 2023; 46:257. [PMID: 37773226 DOI: 10.1007/s10143-023-02160-8] [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: 02/27/2023] [Revised: 09/04/2023] [Accepted: 09/16/2023] [Indexed: 10/01/2023]
Abstract
Cerebral retraction is frequently required in cranial surgery to access deep areas. Brain retractors have been systematically used in the past, but they have been associated with brain injury. Nonetheless, they are still used and, even recently, new systems have been advocated. The aim of this study is to provide a systematic and critical review of brain retraction injury. A systematic literature review was performed in February 2023 according to PRISMA statement. Search terms included brain retraction and injury, with their variations and pertinent associations. Studies reporting qualitative and quantitative data on brain retraction injury were included. Out of 1689 initially retrieved articles, 90 and 26 were included in the systematic review for qualitative and quantitative data, respectively. The definition of brain retraction injury varies and its reported incidence in clinical studies is 5-10%, up to 47% if cerebral edema is considered. Some studies have hypothesized threshold values of pressures to be respected in order to prevent complications, with most data deriving from animal studies. At present, there are no instruments for brain retraction that can guarantee full safety. Some form of cerebral retraction might always be necessary for specific scenarios. Further studies are needed to collect quantitative and, ideally, clinical and comparative data on pressure thresholds to develop retraction systems that can reduce injury to a minimum.
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Affiliation(s)
- Elena Roca
- Head and Neck Department, Neurosurgery, Istituto Ospedaliero Fondazione Poliambulanza, Via Leonida Bissolati n, °57, Brescia, Italy.
| | - Giorgio Ramorino
- Materials Science and Technology at Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
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Omura N, Kawabata S, Yoshimura K, Yagi R, Furuse M, Wanibuchi M. Using virtual lines of navigation for a successful transcortical approach. Surg Neurol Int 2023; 14:171. [PMID: 37292408 PMCID: PMC10246338 DOI: 10.25259/sni_161_2023] [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] [Received: 02/15/2023] [Accepted: 04/28/2023] [Indexed: 06/10/2023] Open
Abstract
Background Neuronavigation systems have become essential tools in image-guided neurosurgery that aid in the accurate resection of brain tumors. Recent advancements to these devices can indicate the precise location of lesions but can also project an augmented reality (AR) image on the microscope eyepiece to facilitate a successful surgical operation. Although the transcortical approach is a very popular method in neurosurgery, it can lead to disorientation and can cause unnecessary brain damage when the distance from the brain surface to the lesion is long. Herein, we report on an actual case in which a virtual line from AR images was used to assist the transcortical approach. Methods A virtual line connecting the entry point and the target point, which were set as the navigation route, was created using Stealth station S7® (Medtronic, Minneapolis, USA). This line was projected as an AR image on the microscope eyepiece. It was possible to reach the target point by proceeding through the white matter along the displayed virtual line. Results The lesion was reached within a short duration using virtual line without disorientation. Conclusion Setting a virtual line as an AR image using neuronavigation is a simple and accurate method that can effectively support the conventional transcortical approach.
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Affiliation(s)
- Naoki Omura
- Corresponding author: Naoki Omura, Department of Neurosurgery, Osaka Medical Pharmaceutical University Hospital, Takatsuki City, Japan.
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Endoscopic transcortical expanded transforaminal transvenous transchoroidal approach to third ventricle lesion resection using an endoport. J Clin Neurosci 2022; 106:166-172. [DOI: 10.1016/j.jocn.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
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Hajtovic S, Sun J, Multani JS, Herrmann LL, Britton H, Gautreaux J, Tortolero L, Harrison G, Golfinos JG, Shepherd TM, Tanweer O, Placantonakis DG. Surgical cytoreduction of deep-seated high-grade glioma through tubular retractor. J Neurosurg 2022:1-12. [PMID: 36334293 DOI: 10.3171/2022.9.jns22842] [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: 04/14/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Maximal safe resection is the goal of surgical treatment for high-grade glioma (HGG). Deep-seated hemispheric gliomas present a surgical challenge due to safety concerns and previously were often considered inoperable. The authors hypothesized that use of tubular retractors would allow resection of deep-seated gliomas with an acceptable safety profile. The purpose of this study was to describe surgical outcomes and survival data after resection of deep-seated HGG with stereotactically placed tubular retractors, as well as to discuss the technical advances that enable such procedures. METHODS This is a retrospective review of 20 consecutive patients who underwent 22 resections of deep-seated hemispheric HGG with the Viewsite Brain Access System by a single surgeon. Patient demographics, survival, tumor characteristics, extent of resection (EOR), and neurological outcomes were recorded. Cannulation trajectories and planned resection volumes depended on the relative location of white matter tracts extracted from diffusion tractography. The surgical plans were designed on the Brainlab system and preoperatively visualized on the Surgical Theater virtual reality SNAP platform. Volumetric assessment of EOR was obtained on the Brainlab platform and confirmed by a board-certified neuroradiologist. RESULTS Twenty adult patients (18 with IDH-wild-type glioblastomas and 2 with IDH-mutant grade IV astrocytomas) and 22 surgeries were included in the study. The cohort included both newly diagnosed (n = 17; 77%) and recurrent (n = 5; 23%) tumors. Most tumors (64%) abutted the ventricular system. The average preoperative and postoperative tumor volumes measured 33.1 ± 5.3 cm3 and 15.2 ± 5.1 cm3, respectively. The median EOR was 93%. Surgical complications included 2 patients (10%) who developed entrapment of the temporal horn, necessitating placement of a ventriculoperitoneal shunt; 1 patient (5%) who suffered a wound infection and pulmonary embolus; and 1 patient (5%) who developed pneumonia. In 2 cases (9%) patients developed new permanent visual field deficits, and in 5 cases (23%) patients experienced worsening of preoperative deficits. Preoperative neurological or cognitive deficits remained the same in 9 cases (41%) and improved in 7 (32%). The median overall survival was 14.4 months in all patients (n = 20) and in the newly diagnosed IDH-wild-type glioblastoma group (n = 16). CONCLUSIONS Deep-seated HGGs, which are surgically challenging and frequently considered inoperable, are amenable to resection through tubular retractors, with an acceptable safety profile. Such cytoreductive surgery may allow these patients to experience an overall survival comparable to those with more superficial tumors.
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Affiliation(s)
- Sabastian Hajtovic
- Departments of1Neurosurgery and.,2The City University of New York (CUNY) School of Medicine, New York, New York
| | | | | | | | | | | | | | - Gillian Harrison
- Departments of1Neurosurgery and.,4Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Omar Tanweer
- 6Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - Dimitris G Placantonakis
- Departments of1Neurosurgery and.,7Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York, New York
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Liu XW, Lu WR, Zhang TY, Hou XS, Fa ZQ, Zhang SZ. Cerebral corridor creator for resection of trigone ventricular tumors: Two case reports. World J Clin Cases 2022; 10:1914-1921. [PMID: 35317166 PMCID: PMC8891768 DOI: 10.12998/wjcc.v10.i6.1914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/04/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Resection of deep intracranial tumors requires significant brain retraction, which frequently causes brain damage. In particular, tumor in the trigone of the lateral ventricular presents a surgical challenge due to its inaccessible location and intricate adjacent relationships with essential structures such as the optic radiation (OR) fibers. New brain retraction systems have been developed to minimize retraction-associated injury. To date, there is little evidence supporting the superiority of any retraction system in preserving the white matter tract integrity. This report illustrates the initial surgical excision in two patients using a new retraction system termed the cerebral corridor creator (CCC) and demonstrates its advantage in protecting OR fibers.
CASE SUMMARY We report two patients with nonspecific symptoms, who had trigone ventricular lesions that involved the neighboring OR identified on preoperative diffusion tensor imaging (DTI). Both patients underwent successful surgical excision using the CCC. Total tumor removal was achieved without additional neurological deficit. DTI showed that the OR fibers were preserved along the surgical field. Preoperative symptoms were alleviated immediately after surgery. Clinical outcomes were improved according to the Glasgow-Outcome-Scale and Activity-of-Daily-Living Scale assessments.
CONCLUSION In the two cases, the CCC was a safe and useful tool for creating access to the deep trigonal area while preserving the white matter tract integrity. The CCC is thus a promising alternative brain retractor.
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Affiliation(s)
- Xing-Wu Liu
- Department of Functional Neurosurgery, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Wei-Rong Lu
- Department of Radiology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Tian-Yi Zhang
- General Hospital of Xinjiang Military Region, Shihezi University, Urumqi 830000, Xinjiang Uygur Autonomous Region, China
| | - Xu-Sheng Hou
- Department of Functional Neurosurgery, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Zhi-Qiang Fa
- Department of Functional Neurosurgery, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province, China
| | - Shi-Zhong Zhang
- Department of Functional Neurosurgery, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, Guangdong Province, China
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