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Thakkar K, Thomas JT, Hrishi AP, Sethuraman M. Decoding the Onset of Intraoperative Normal Pressure Perfusion Breakthrough with Near-Infrared Spectroscopy and Jugular Venous Oxygen Saturation Catheter in a Case of Arteriovenous Malformation Surgery. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1732831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractMultimodal monitoring can be a useful tool to design an appropriate anesthesia technique in the intraoperative period during the surgical excision of an intracerebral arteriovenous malformation (AVM). Intraoperatively, hyperperfusion syndrome can be attributed to causes like insufficient blood pressure control, occlusion of venous drainage before complete resection of arterial feeders, or inadequate hemostatic control of distended capillaries receiving arterial flow. We would like to highlight the potential role of near-infrared spectroscopy and jugular venous oxygen saturation catheter in detection of intraoperative normal perfusion pressure breakthrough and take necessary measures to prevent further insult with the help of this case report.
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Affiliation(s)
- Keta Thakkar
- Division of Neuroanaesthesiology and Neurocritical Care, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jithumol T. Thomas
- Division of Neuroanaesthesiology and Neurocritical Care, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajay P. Hrishi
- Division of Neuroanaesthesiology and Neurocritical Care, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Manikandan Sethuraman
- Division of Neuroanaesthesiology and Neurocritical Care, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Ajayan N, Hrishi AP, Nagendra V, Sethuraman M. Role of Multimodal Cerebral Oximetry Monitoring in the Anesthetic Management of a Patient With High-Grade Intracranial Arteriovenous Malformation: A Case Report. A A Pract 2020; 14:e01192. [PMID: 32784313 DOI: 10.1213/xaa.0000000000001192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Near-infrared spectroscopy (NIRS) is a noninvasive monitor of regional brain tissue oxygenation, and jugular venous oximetry (SjvO2) is a monitor of global cerebral oxygenation. We report the role of intraoperative multimodal monitoring of cerebral oxygenation in the anesthetic management of a patient with grade III intracranial arteriovenous malformation (AVM) presenting for surgical excision. Real-time monitoring of cerebral oxygenation is of much relevance in high-grade AVMs where anesthetic management is focused on neuroprotection and prevention of cerebral hypoxia. Besides, it also helps in prediction, early detection, and judicious management of perioperative complications, which are commonly encountered in high-grade AVMs.
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Affiliation(s)
- Neeraja Ajayan
- From the Division of Neuroanesthesia, Department of Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Robba C, Asgari S, Gupta A, Badenes R, Sekhon M, Bequiri E, Hutchinson PJ, Pelosi P, Gupta A. Lung Injury Is a Predictor of Cerebral Hypoxia and Mortality in Traumatic Brain Injury. Front Neurol 2020; 11:771. [PMID: 32849225 PMCID: PMC7426476 DOI: 10.3389/fneur.2020.00771] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/23/2020] [Indexed: 12/19/2022] Open
Abstract
Background: A major contributor to unfavorable outcome after traumatic brain injury (TBI) is secondary brain injury. Low brain tissue oxygen tension (PbtO2) has shown to be an independent predictor of unfavorable outcome. Although PbtO2 provides clinicians with an understanding of the ischemic and non-ischemic derangements of brain physiology, its value does not take into consideration systemic oxygenation that can influence patients' outcomes. This study analyses brain and systemic oxygenation and a number of related indices in TBI patients: PbtO2, partial arterial oxygenation pressure (PaO2), PbtO2/PaO2, ratio of PbtO2 to fraction of inspired oxygen (FiO2), and PaO2/FiO2. The primary aim of this study was to identify independent risk factors for cerebral hypoxia. Secondary goal was to determine whether any of these indices are predictors of mortality outcome in TBI patients. Materials and Methods: A single-centre retrospective cohort study of 70 TBI patients admitted to the Neurocritical Care Unit (NCCU) at Cambridge University Hospital in 2014-2018 and undergoing advanced neuromonitoring including invasive PbtO2 was conducted. Three hundred and three simultaneous measurements of PbtO2, PaO2, PbtO2/PaO2, PbtO2/FiO2, PaO2/FiO2 were collected and mortality at discharge from NCCU was considered as outcome. Generalized estimating equations were used to analyse the longitudinal data. Results: Our results showed PbtO2 of 28 mmHg as threshold to define cerebral hypoxia. PaO2/FiO2 found to be a strong and independent risk factor for cerebral hypoxia when adjusting for confounding factor of intracranial pressure (ICP) with adjusted odds ratio of 1.78, 95% confidence interval of (1.10-2.87) and p-value = 0.019. With respect to TBI outcome, compromised values of PbtO2, PbtO2/PaO2, PbtO2/FiO2, and PaO2/FiO2 were all independent predictors of mortality while considered individually and adjusting for confounding factors of ICP, age, gender, and cerebral perfusion pressure (CPP). However, when considering all the compromised values together, only PaO2/FiO2 became an independent predictor of mortality with adjusted odds ratio of 3.47 (1.20-10.04) and p-value = 0.022. Conclusions: Brain and Lung interaction in TBI patients is a complex interrelationship. PaO2/FiO2 seems to be a major determinant of cerebral hypoxia and mortality. These results confirm the importance of employing ventilator strategies to prevent cerebral hypoxia and improve the outcome in TBI patients.
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Affiliation(s)
- Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Shadnaz Asgari
- Biomedical Engineering Department, California State University, Long Beach, CA, United States.,Computer Engineering and Computer Science Department, California State University, Long Beach, CA, United States
| | - Amit Gupta
- Emergency Department, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, United Kingdom
| | - Rafael Badenes
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Erta Bequiri
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Peter J Hutchinson
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università Degli Studi di Genova, Genoa, Italy
| | - Arun Gupta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos. Neurocirugia (Astur) 2020; 31:24-36. [DOI: 10.1016/j.neucir.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 01/20/2023]
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Fennell VS, Martirosyan NL, Atwal GS, Kalani MYS, Ponce FA, Lemole GM, Dumont TM, Spetzler RF. Hemodynamics Associated With Intracerebral Arteriovenous Malformations: The Effects of Treatment Modalities. Neurosurgery 2017; 83:611-621. [DOI: 10.1093/neuros/nyx560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 10/13/2017] [Indexed: 12/22/2022] Open
Abstract
Abstract
The understanding of the physiology of cerebral arteriovenous malformations (AVMs) continues to expand. Knowledge of the hemodynamics of blood flow associated with AVMs is also progressing as imaging and treatment modalities advance. The authors present a comprehensive literature review that reveals the physical hemodynamics of AVMs, and the effect that various treatment modalities have on AVM hemodynamics and the surrounding cortex and vasculature. The authors discuss feeding arteries, flow through the nidus, venous outflow, and the relative effects of radiosurgical monotherapy, endovascular embolization alone, and combined microsurgical treatments. The hemodynamics associated with intracranial AVMs is complex and likely changes over time with changes in the physical morphology and angioarchitecture of the lesions. Hemodynamic change may be even more of a factor as it pertains to the vast array of single and multimodal treatment options available. An understanding of AVM hemodynamics associated with differing treatment modalities can affect treatment strategies and should be considered for optimal clinical outcomes.
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Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - G Michael Lemole
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Vidal-Jorge M, Sánchez-Guerrero A, Mur-Bonet G, Castro L, Rădoi A, Riveiro M, Fernández-Prado N, Baena J, Poca MA, Sahuquillo J. Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker. J Neurotrauma 2017; 34:2731-2742. [PMID: 28323516 DOI: 10.1089/neu.2017.4992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.
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Affiliation(s)
- Marian Vidal-Jorge
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Angela Sánchez-Guerrero
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Gemma Mur-Bonet
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Lidia Castro
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Andreea Rădoi
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Marilyn Riveiro
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Fernández-Prado
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jacinto Baena
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Antonia Poca
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sahuquillo
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
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Arikan F, Martínez-Valverde T, Sánchez-Guerrero Á, Campos M, Esteves M, Gandara D, Torné R, Castro L, Dalmau A, Tibau J, Sahuquillo J. Malignant infarction of the middle cerebral artery in a porcine model. A pilot study. PLoS One 2017; 12:e0172637. [PMID: 28235044 PMCID: PMC5325275 DOI: 10.1371/journal.pone.0172637] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 02/07/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Interspecies variability and poor clinical translation from rodent studies indicate that large gyrencephalic animal stroke models are urgently needed. We present a proof-of-principle study describing an alternative animal model of malignant infarction of the middle cerebral artery (MCA) in the common pig and illustrate some of its potential applications. We report on metabolic patterns, ionic profile, brain partial pressure of oxygen (PtiO2), expression of sulfonylurea receptor 1 (SUR1), and the transient receptor potential melastatin 4 (TRPM4). METHODS A 5-hour ischemic infarct of the MCA territory was performed in 5 2.5-to-3-month-old female hybrid pigs (Large White x Landrace) using a frontotemporal approach. The core and penumbra areas were intraoperatively monitored to determine the metabolic and ionic profiles. To determine the infarct volume, 2,3,5-triphenyltetrazolium chloride staining and immunohistochemistry analysis was performed to determine SUR1 and TRPM4 expression. RESULTS PtiO2 monitoring showed an abrupt reduction in values close to 0 mmHg after MCA occlusion in the core area. Hourly cerebral microdialysis showed that the infarcted tissue was characterized by reduced concentrations of glucose (0.03 mM) and pyruvate (0.003 mM) and increases in lactate levels (8.87mM), lactate-pyruvate ratio (4202), glycerol levels (588 μM), and potassium concentration (27.9 mmol/L). Immunohistochemical analysis showed increased expression of SUR1-TRPM4 channels. CONCLUSIONS The aim of the present proof-of-principle study was to document the feasibility of a large animal model of malignant MCA infarction by performing transcranial occlusion of the MCA in the common pig, as an alternative to lisencephalic animals. This model may be useful for detailed studies of cerebral ischemia mechanisms and the development of neuroprotective strategies.
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Affiliation(s)
- Fuat Arikan
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- * E-mail:
| | - Tamara Martínez-Valverde
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ángela Sánchez-Guerrero
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Campos
- Experimental Surgery Unit, Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marielle Esteves
- Experimental Surgery Unit, Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dario Gandara
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramon Torné
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lidia Castro
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoni Dalmau
- IRTA, Animal Breeding and Genetics Program, Monells, Girona, Spain
| | - Joan Tibau
- IRTA, Animal Breeding and Genetics Program, Monells, Girona, Spain
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
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Badenes R, García-Pérez ML, Bilotta F. Intraoperative monitoring of cerebral oximetry and depth of anaesthesia during neuroanesthesia procedures. Curr Opin Anaesthesiol 2016; 29:576-81. [DOI: 10.1097/aco.0000000000000371] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Arikan F, Vilalta J, Torne R, Noguer M, Lorenzo-Bosquet C, Sahuquillo J. Rapid resolution of brain ischemic hypoxia after cerebral revascularization in moyamoya disease. Neurosurgery 2015; 76:302-12; discussion 312. [PMID: 25584958 DOI: 10.1227/neu.0000000000000609] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In moyamoya disease (MMD), cerebral revascularization is recommended in patients with recurrent or progressive ischemic events and associated reduced cerebral perfusion reserve. Low-flow bypass with or without indirect revascularization is generally the standard surgical treatment. Intraoperative monitoring of cerebral partial pressure of oxygen (PtiO2) with polarographic Clark-type probes in cerebral artery bypass surgery for MMD-induced chronic cerebral ischemia has not yet been described. OBJECTIVE To describe basal brain tissue oxygenation in MMD patients before revascularization as well as the immediate changes produced by the surgical procedure using intraoperative PtiO2 monitoring. METHODS Between October 2011 and January 2013, all patients with a diagnosis of MMD were intraoperatively monitored. Cerebral oxygenation status was analyzed based on the Ptio2/PaO2 ratio. Reference thresholds of PtiO2/PaO2 had been previously defined as below 0.1 for the lower reference threshold (hypoxia) and above 0.35 for the upper reference threshold (hyperoxia). RESULTS Before STA-MCA bypass, all patients presented a situation of severe tissue hypoxia confirmed by a PtiO2/PaO2 ratio <0.1. After bypass, all patients showed a rapid and sustained increase in PtiO2, which reached normal values (PtiO2/PaO2 ratio between 0.1 and 0.35). One patient showed an initial PtiO2 improvement followed by a decrease due to bypass occlusion. After repeat anastomosis, the patient's PtiO2 increased again and stabilized. CONCLUSION Direct anastomosis quickly improves cerebral oxygenation, immediately reducing the risk of ischemic stroke in both pediatric and adult patients. Intraoperative PtiO2 monitoring is a very reliable tool to verify the effectiveness of this revascularization procedure.
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Affiliation(s)
- Fuat Arikan
- *Department of Neurosurgery and the Neurotraumatology and Neurosurgery Research Unit (UNINN); ‡Departments of Anesthesiology and §Nuclear Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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Arikan F, Vilalta J, Torne R, Chocron I, Rodriguez-Tesouro A, Sahuquillo J. Monitorización intraoperatoria de la presión tisular de oxígeno: aplicaciones en neurocirugía vascular. Neurocirugia (Astur) 2014; 25:275-85. [DOI: 10.1016/j.neucir.2014.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/17/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
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