1
|
Yoshimura Y, Kanda-Kikuchi J, Hara T, Sugimoto I. Idiopathic hypertrophic pachymeningitis in a patient with a history of diffuse large B cell lymphoma. BMJ Case Rep 2023; 16:e254847. [PMID: 37316284 PMCID: PMC10277052 DOI: 10.1136/bcr-2023-254847] [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: 06/16/2023] Open
Abstract
A man in his early 70s with a 4-year history of diffuse large B cell lymphoma (DLBCL) was admitted to our hospital with diplopia and achromatopsia. Neurological examination revealed visual impairment, ocular motility disorder and diplopia on looking to the left. Blood and cerebrospinal fluid investigations showed no significant findings. MRI revealed diffusely thickened dura mater and contrast-enhanced structures in the left apical orbit, consistent with hypertrophic pachymeningitis (HP). We performed an open dural biopsy to distinguish the diagnosis from lymphoma. The pathological diagnosis was idiopathic HP, and DLBCL recurrence was ruled out. Following methylprednisolone pulse and oral prednisolone therapy, his neurological abnormalities gradually receded. Open dural biopsy played an important role not only in diagnosing idiopathic HP but also in relieving the pressure on the optic nerve.
Collapse
Affiliation(s)
- Yusuke Yoshimura
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Junko Kanda-Kikuchi
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Izumi Sugimoto
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Kanagawa, Japan
| |
Collapse
|
2
|
Singh VK, Kalita J, Misra UK, Kumar S. Cerebral Venous Sinus Thrombosis and Pachymeningitis in IgG4 Related Disease: Report of Two Cases and Review of Literature. Ann Indian Acad Neurol 2021; 24:432-436. [PMID: 34447016 PMCID: PMC8370182 DOI: 10.4103/aian.aian_411_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Varun K Singh
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| | - Sunil Kumar
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India
| |
Collapse
|
3
|
Yao A, Jia L, Wang B, Zhang J, Zhang J, Xu B. Idiopathic Hypertrophic Pachymeningitis Mimicking Meningioma with Occlusion of Superior Sagittal Sinus: Case Report and Review of Literature. World Neurosurg 2019; 127:534-537. [PMID: 30965168 DOI: 10.1016/j.wneu.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Idiopathic hypertrophic pachymeningitis is a rare inflammatory condition with diffuse thickening of the dura mater, which may cause a compressive effect or vascular compromise. CASE DESCRIPTION A 40-year-old Chinese man presented with persistent headache for 6 months and a sudden epileptic seizure 2 days ago. Magnetic resonance imaging demonstrated a large (71 × 34 × 27 mm) extra-axial mass at the right frontal convexity with severe edema mimicking meningioma. The lesion and peripheral dura mater showed contrast enhancement. Additionally, the skull near the lesion was eroded. Meningioma was diagnosed, and the patient underwent surgery. During the operation, we found the lesion texture was very tough, and the superior sagittal sinus was occluded. Histopathologic findings revealed a large number of infiltrated lymphocytes with fibrosis and microabscess formation; intracranial idiopathic hypertrophic pachymeningitis was diagnosed. Follow-up magnetic resonance imaging performed 3 months after surgery demonstrated the enhancement was notably alleviated. CONCLUSIONS Idiopathic hypertrophic pachymeningitis should be part of the differential diagnosis of some cases of meningioma.
Collapse
Affiliation(s)
- Anhui Yao
- Department of Neurosurgery, General Hospital of PLA, Beijing, China; Department of Neurosurgery, The 988 Hospital of PLA, Zhengzhou, China
| | - Liyun Jia
- Department of Medical Genetics and Cell Biology, School of Basic Medical Science, Zhengzhou University, Zhengzhou, China
| | - Benhan Wang
- Department of Neurosurgery, The 988 Hospital of PLA, Zhengzhou, China
| | - Jiashu Zhang
- Department of Neurosurgery, General Hospital of PLA, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, General Hospital of PLA, Beijing, China.
| | - Bainan Xu
- Department of Neurosurgery, General Hospital of PLA, Beijing, China
| |
Collapse
|
4
|
Huang K, Xu Q, Ma Y, Zhan R, Shen J, Pan J. Cerebral Venous Sinus Thrombosis Secondary to Idiopathic Hypertrophic Cranial Pachymeningitis: Case Report and Review of Literature. World Neurosurg 2017; 106:1052.e13-1052.e21. [PMID: 28711538 DOI: 10.1016/j.wneu.2017.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 07/01/2017] [Accepted: 07/05/2017] [Indexed: 12/24/2022]
Abstract
BACKGOUND AND IMPORTANCE Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare fibrosing inflammatory process involving the dura mater. Currently, there is no consensus on the treatments for IHCP, and the usefulness of immunosuppressive agents as a first-line option remains controversial. Cerebral venous sinus occlusion (CVSO) and cerebral venous sinus thrombosis (CVST) secondary to IHCP, which may cause progressive intracranial hypertension and venous obstructive parenchymal lesions, make the diagnosis and treatment of IHCP more complicated. METHODS We present a case of IHCP. We also review previous cases of IHCP with secondary CVSO/CVST and then summarize the clinical characteristics of these patients. CLINICAL PRESENTATION A 52-year-old female patient with IHCP developed secondary CVST. She had a severe headache with a hyperintense lesion on computed tomography, which was considered as subarachnoid hemorrhage. Lumbar tapping with a cerebrospinal fluid test, in addition to gadolinium contrast-enhanced magnetic resonance imaging, suggested IHCP. Secondary CVST was identified by digital subtraction angiography and magnetic resonance venography. Fatal intracranial hypertension with severe neurologic deficits occurred, despite mannitol, furosemide, and corticoid therapy. After administration of intravenous pulse cyclophosphamide, she obtained complete remission. CONCLUSIONS We experienced a patient with CVST secondary to IHCP, who was successfully treated with cyclophosphamide pulse therapy. Because IHCP with secondary venous obstruction has various differential diagnoses, venography is necessary to avoid misdiagnosis. The use of immunosuppressive agents may be promising but needs further verification.
Collapse
Affiliation(s)
- Kaiyuan Huang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Qingsheng Xu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yuankun Ma
- Department of Cardiology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Renya Zhan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Jian Shen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China.
| | - Jianwei Pan
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, People's Republic of China
| |
Collapse
|
5
|
De Virgilio A, de Vincentiis M, Inghilleri M, Fabrini G, Conte M, Gallo A, Rizzo MI, Greco A. Idiopathic hypertrophic pachymeningitis: an autoimmune IgG4-related disease. Immunol Res 2016; 65:386-394. [DOI: 10.1007/s12026-016-8863-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
6
|
Dziedzic T, Wojciechowski J, Nowak A, Marchel A. Hypertrophic pachymeningitis. Childs Nerv Syst 2015; 31:1025-31. [PMID: 25771924 DOI: 10.1007/s00381-015-2680-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases. CASE DESCRIPTION We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.
Collapse
Affiliation(s)
- Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland,
| | | | | | | |
Collapse
|
7
|
Borha A, Emery E, Courtheoux P, Lefevre P, Derlon JM. Tentorial dural fistula with giant venous ampulae treated with embolisation and surgery. A case report. Acta Neurochir (Wien) 2010; 152:1745-53. [PMID: 20635104 DOI: 10.1007/s00701-010-0722-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
Abstract
Tentorial dural arteriovenous fistulas are rare and complex lesions in deep locations with unusual vascular anatomy and critical surrounding neuroanatomy. A rare case presenting a complex fistula with a giant venous draining ampulae, causing headaches and visual troubles is presented. We describe the case of a 52-year-old woman admitted in our department for headaches and visual troubles. Magnetic resonance imaging and cerebral angiography showed a tentorial dural arteriovenous fistula draining in a giant tentorial venous ampulae and leptomeningeal veins. The patient was embolised via an arterial route with a good clinical and radiological result. However, 4 days later she presented a sudden change of her clinical status with coma, left hemiparesis and a right midriasis. The cerebral computed tomography scan showed a huge occipital haemorrhagic mass and a severe cerebral oedema. An emergent surgical procedure was decided realising evacuation of the occipital haematoma and a complete resection of the giant venous ampoule. The neck of the ampulae was sutured and clipped at its dural entrance. Postoperatively a new embolisation was realised because of persistent of a small dural fistulae with occipital leptomeningeal drainage. The patient recovered rapidly with only a residual hemianopsy. Treatment of dural AV malformation represent a serious challenge. Our report describes an unusual case of a tentorial dural complex fistula treated by an endovascular procedure with secondary clinical aggravation that needed emergent surgical therapy. Even in a case for good immediate radiological result after endovascular procedure, dural arteriovenous fistulas with giant venous ampulae and important venous engorgement, need closed follow-up, because of the possibility of aggravation secondary to venous thrombosis and haemorrhage. Treatment and patophysiology of the aggravation mechanism are discussed.
Collapse
|
8
|
Bhatia R, Tripathi M, Srivastava A, Garg A, Singh MB, Nanda A, Padma MV, Prasad K. Idiopathic hypertrophic cranial pachymeningitis and dural sinus occlusion: two patients with long-term follow up. J Clin Neurosci 2009; 16:937-42. [PMID: 19375919 DOI: 10.1016/j.jocn.2008.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 06/20/2008] [Accepted: 08/17/2008] [Indexed: 10/20/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHPM) is a clinicopathological entity characterized by thickening and fibrosis of the dura mater with resultant clinical symptoms. It is generally steroid responsive and has a tendency to remit and relapse. We present here two patients with IHPM with associated dural sinus occlusion and describe their clinicoradiological features and long-term course and outcome.
Collapse
Affiliation(s)
- R Bhatia
- Department of Neurology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Moura FC, Pereira IC, Gonçalves ACP, Marchiori PE, Monteiro MLR. Paquimeningite hipertrófica idiopática craniana associada a pseudotumor orbitário: relato de caso. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:885-8. [PMID: 16258678 DOI: 10.1590/s0004-282x2005000500034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Paquimeningite hipertrófica se caracteriza por espessamento das meninges, podendo ser decorrente de infecção, infiltração tumoral, doença inflamatória ou idiopática. Relatamos sobre um homem de, 40 anos, com queixa de cefaléia de longa data e perda progressiva da visão em ambos os olhos acompanhadas de proptose bilateral. A imagem por ressonância magnética de crânio e órbitas revelou espessamento dural difuso e lesão orbitária bilateral. Extensa investigação não revelou qualquer afecção sistêmica. Estudo anatomopatológico realizado após biópsias de meninges e da massa orbitária evidenciou processo inflamatório crônico compatível com paquimeningite hipertrófica idiopática (PHI) e com pseudotumor orbitário respectivamente. Este caso evidencia que o acometimento orbitário pode ocorrer na PHI e que a sua identificação precoce é de fundamental importância para o prognóstico visual.
Collapse
Affiliation(s)
- Frederico Castelo Moura
- Divisão de Clínica Oftalmológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
| | | | | | | | | |
Collapse
|
10
|
Muthukumar N, Senthilbabu S, Usharani K. Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome. J Clin Neurosci 2005; 12:589-92. [PMID: 16051099 DOI: 10.1016/j.jocn.2004.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2003] [Accepted: 08/05/2004] [Indexed: 10/25/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis is a rare condition. A case of idiopathic hypertrophic cranial pachymeningitis presenting as Tolosa-Hunt syndrome is being reported. The importance of neuroimaging in patients with suspected Tolosa-Hunt syndrome is discussed. Tolosa-Hunt syndrome might represent a focal manifestation of Idiopathic hypertrophic cranial pachymeningitis. Future studies are necessary to further clarify the relationship between these two conditions.
Collapse
Affiliation(s)
- N Muthukumar
- Department of Neurosurgery, Madurai Medical College, Madurai, India.
| | | | | |
Collapse
|
11
|
Tuncel D, Yücesan C, Erden E, Savaş A, Erden I, Mutluer N. Idiopathic hypertrophic cranial pachymeningitis with perifocal brain edema. Clin Neurol Neurosurg 2005; 107:249-52. [PMID: 15823684 DOI: 10.1016/j.clineuro.2004.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 05/24/2004] [Accepted: 06/08/2004] [Indexed: 10/26/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) consists of meningeal thickening due to chronic inflammation for which no cause such as infection, specific granulomatous disease, or malignancy is demonstrable. We present a case of IHCP with perifocal brain edema suggesting mass lesion with its magnetic resonance imaging (MRI) and pathologic findings. A 36-year-old woman was admitted to our hospital in August 2001 with a complaint of motor weakness in her left leg for 1 month. Magnetic resonance imaging with gadolinium revealed enhancement of the thickened dura mater and perifocal edema in the right frontoparietal region suggesting a mass lesion. Histological examination of the biopsy specimen revealed a dense fibrous cellular tissue. There was no obvious inflammatory infiltrate but in some areas between fibrous bundles one or two lymphocytes were detected. According to our knowledge, our patient is the second report in the literature of IHCP with focal edema causing a mass effect.
Collapse
Affiliation(s)
- Deniz Tuncel
- Department of Neurology, Ankara University Faculty of Medicine, Ankara, Turkey.
| | | | | | | | | | | |
Collapse
|
12
|
Kanzaki S, Inoue Y, Watabe T, Ogawa K. Hypertrophic chronic pachymeningitis associated with chronic otitis media and mastoiditis. Auris Nasus Larynx 2005; 31:155-9. [PMID: 15121225 DOI: 10.1016/j.anl.2004.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2003] [Accepted: 01/16/2004] [Indexed: 11/20/2022]
Abstract
We describe the case history of a 70-year-old female patient presenting with bilateral hearing disturbance, facial paralysis, and vertigo. Radiological tests of temporal bone revealed soft tissue in the mastoid and tympanic cavities, and T1 weighted MRI revealed prominent Gd enhancement of the middle skull basal meninges. Middle ear inflammation appeared to induce pachymeningitis and to exacerbate associated symptoms, leading to a decline in the patient's overall condition. Bilateral mastoidectomies were effective in improving her general condition. Her hearing improved only on the right side because ossiculoplasty was performed only on that side. Her facial movement progressively improved and pachymeningitis diminished over time. We speculate that removal of the infectious granulation within the middle ears and mastoids ameliorated the acute inflammation. The etiology remains unknown in this case.
Collapse
Affiliation(s)
- Sho Kanzaki
- Department of Otolaryngology, Head and Neck Surgery, Keio University Hospital, 35 Shinanomachi, Shinjuku, Tokyo 160-0082, Japan.
| | | | | | | |
Collapse
|
13
|
Kon T, Ishihara N, Kamimura T, Tanaka R, Ito J, Horikawa Y, Saito I. Unusual MRI findings of hypertrophic pachymeningitis with irregular dural thickening and severe brain oedema. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.ejrex.2004.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
D'Andrea G, Trillò G, Celli P, Roperto R, Crispo F, Ferrante L. Idiopathic intracranial hypertrophic pachymeningitis: two case reports and review of the literature. Neurosurg Rev 2004; 27:199-204. [PMID: 15007702 DOI: 10.1007/s10143-004-0321-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2003] [Revised: 10/28/2003] [Accepted: 10/30/2003] [Indexed: 11/29/2022]
Abstract
In 1949, Naffziger et al. first described idiopathic intracranial hypertrophic pachymeningitis (IIHP) as an aseptic, diffuse inflammatory disease that causes thickening of the dura mater and often headache and progressive multiple nerve palsies due to fibrous entrapment or ischemic damage of neurovascular structures. Pachymeningeal thickening can be diffuse or nodular. We report two cases of IIHP; one was affected by diffuse IIHP, while the other presented focal IIHP mimicking a convexity meningioma. We examine the differential diagnosis between IIHP and other known causes of hypertrophic pachymeningitis. We also discuss the clinical bases of treatment.
Collapse
Affiliation(s)
- Giancarlo D'Andrea
- Department of Neurological Sciences, Faculty of Medicine II, La Sapienza University, S. Andrea Hospital, Rome, Italy.
| | | | | | | | | | | |
Collapse
|
15
|
Oiwa Y, Hyotani G, Kamei I, Itakura T. Idiopathic Hypertrophic Cranial Pachymeningitis Associated With Total Occlusion of the Dural Sinuses-Case Report-. Neurol Med Chir (Tokyo) 2004; 44:650-4. [PMID: 15684597 DOI: 10.2176/nmc.44.650] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 44-year-old man presented with a rare case of idiopathic hypertrophic cranial pachymeningitis manifesting as generalized seizure. Neuroimaging and pathological examinations showed the typical features of hypertrophic cranial pachymeningitis. Tuberculosis was a possible cause based on the positive purified protein-derived skin test, but the origin of the disease was not confirmed by further examinations. Cerebral angiography showed total occlusion of the dural sinuses with development of the emissary veins. Histological examination of the dura showed thickening of the fibrous tissue with rare inflammatory cells, suggestive of the extremely long duration of the disease. The diagnosis was idiopathic hypertrophic cranial pachymeningitis, but was treated only with anticonvulsants. The disease did not progress during follow up of 3 years. Idiopathic hypertrophic cranial pachymeningitis may have various causes related to unusual forms of infectious or autoimmune disorders.
Collapse
Affiliation(s)
- Yoshitsugu Oiwa
- Department of Neurological Surgery, Wakayama Medical University, Wakayama, Japan.
| | | | | | | |
Collapse
|