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Pepper J, Lamin S, Thomas A, Walsh AR, Rodrigues D, Lo WB, Solanki GA. Clinical features and outcome in pediatric arteriovenous malformation: institutional multimodality treatment. Childs Nerv Syst 2022; 39:975-982. [PMID: 36580118 DOI: 10.1007/s00381-022-05800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Intracranial arteriovenous-malformation (AVM) is a relatively rare condition in pediatrics, yet is a major cause of spontaneous intracranial hemorrhage with a risk of fatal hemorrhage reported to be between 4 and 29%. Little is known about vessel morphology and optimum treatment modalities including multimodality combination therapy and prognosis in children. METHODS A retrospective review of all children presenting to our institution from 2006 to 2020 that had an AVM was undertaken. RESULTS A total of 50 children were identified with median age of 11 (range 1-16) years. The mean follow-up was 7.6 years. Forty-one children presented as an emergency and of those, 40 had hemorrhage identified on initial brain imaging. The average nidus size was 25 mm, drainage was superficial in 51% of cases, and located in eloquent cortex in 56%. The supplemental Spetzler-Martin grading indicated 78% (39/50) were grade 4 and above (moderate to high risk). Primary treatment modalities included embolization in 50% (25) or SRS in 30% (15) and surgery in 20% (10).The AVM was obliterated on follow-up DSA in 66% children. Three children had post-treatment hemorrhage, two related to embolization and one the day following SRS, giving a re-bleed rate of 6%. The GOSE was available for 32 children at long term follow and 94% had a good outcome (GOSE 5-8). Two children died due to acute hemorrhage (4%). CONCLUSION The majority of children with AVM present with hemorrhage. The rebleed rate during definitive treatment is low at 6% over the study period. The selective use of the 3 modalities of treatment has significantly reduced mortality and severe disability.
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Affiliation(s)
- Joshua Pepper
- Birmingham Women's & Children's Hospital, Birmingham, UK.
| | - Saleh Lamin
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Allan Thomas
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | | | | | - William B Lo
- Birmingham Women's & Children's Hospital, Birmingham, UK
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Oulasvirta E, Pohjola A, Koroknay-Pál P, Hafez A, Roine R, Sintonen H, Laakso A. Long-term health-related quality of life in patients with ruptured arteriovenous malformations treated in childhood. J Neurosurg Pediatr 2022; 30:292-300. [PMID: 35901751 DOI: 10.3171/2022.5.peds2284] [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: 03/05/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to reveal the long-term health-related quality of life (HRQOL), educational level, and impact on occupation in 55 patients who experienced ruptured brain arteriovenous malformations (AVMs) that were treated during childhood. METHODS In 2016, questionnaires including the 15D instrument were sent to all living patients older than 18 years (n = 432) in the Helsinki AVM database. The cohort was further specified to include only patients with ruptured AVMs who were younger than 20 years at the time of diagnosis (n = 55). Educational level was compared with the age-matched general population of Finland. The mean 15D scores were calculated for independent variables (Spetzler-Ponce classification, admission age, symptomatic epilepsy, and multiple bleeding episodes) and tested using the independent-samples t-test or ANCOVA. Linear regression was used to create a multivariate model. Bonferroni correction was used with multiple comparisons. RESULTS The mean follow-up time from diagnosis to survey was 24.2 (SD 14.7) years. The difference in the mean 15D scores between Spetzler-Ponce classes did not reach statistical significance. The youngest age group (< 10 years at the time of diagnosis) performed less well on the dimension of usual activities than the older patients. Symptomatic epilepsy significantly reduced the long-term HRQOL. Multiple hemorrhages significantly reduced the scores on three dimensions: mobility, speech, and sexual activity. In the regression model, symptomatic epilepsy was the only significant predictor for a lower 15D score. The educational level of the cohort was for the most part comparable to that of the general population in the same age group. AVM was the reason for early retirement in 11% of the patients, while lowered performance because of the AVM was reported by 37% of the patients. CONCLUSIONS Patients with ruptured AVMs treated in childhood can live an independent and meaningful life, even in the case of the highest-grade lesions. Symptomatic epilepsy significantly reduced the long-term HRQOL, highlighting the need for continuing support for these patients.
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Affiliation(s)
- Elias Oulasvirta
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Anni Pohjola
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Päivi Koroknay-Pál
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Ahmad Hafez
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Risto Roine
- 2Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland; and
| | - Harri Sintonen
- 3Department of Public Health, Helsinki University Hospital, Helsinki, Finland
| | - Aki Laakso
- 1Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
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3
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Taylor HL, Dove EJ, Elverum CL, Gunther WM. Sudden death caused by ruptured brain arteriovenous malformation in an adolescent with autism spectrum disorder. J Forensic Sci 2022; 67:1734-1738. [PMID: 35246983 DOI: 10.1111/1556-4029.15024] [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: 11/16/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are infrequent disorders in the pediatric population. The rupture of a bAVM is a clinical emergency often followed by death. Autism spectrum disorder shares a number of symptoms with AVM malformation; this may impede antemortem diagnosis. An 11-year-old boy with autism spectrum disorder (ASD) without other medical history died suddenly. Initially, choking on a peanut butter sandwich was suspected; autopsy did not demonstrate aspiration, but identified a ruptured right cerebellar AVM, with the characteristic tortuous vessels. The histology on the lesion confirmed the presence of arterialized veins and showed gliotic tissue and hemosiderin-laden macrophages, consistent with prior bleeding. BAVM pathogenesis is unknown; congenital disease may have several mechanisms including genetic predisposition and familial risk factors; development de novo may occur after hemorrhagic intracranial events such as surgical intervention and head trauma. ASD may present with overlapping symptoms of bAVM and may also interfere with expressing subtle neurologic symptoms to caretakers. ASD and AVM are rarely reported in association.
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Affiliation(s)
- Haley L Taylor
- Department of Pathology and Laboratory Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eric J Dove
- Pathology Department, State University at New York (SUNY) University at Buffalo, Buffalo, New York, USA
| | - Cassandra L Elverum
- Children's Hospital of the King's Daughters Child Advocacy Center, Norfolk, Virginia, USA
| | - Wendy M Gunther
- Office of the Chief Medical Examiner, Commonwealth of Virginia, Norfolk, Virginia, USA
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Effect of Cinepazide Maleate on Serum Inflammatory Factors of ICU Patients with Severe Cerebral Hemorrhage after Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6562140. [PMID: 34745295 PMCID: PMC8568541 DOI: 10.1155/2021/6562140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/15/2021] [Indexed: 12/01/2022]
Abstract
Objective To explore the effect of cinepazide maleate on serum inflammatory factors of intensive care unit (ICU) patients with severe cerebral hemorrhage after surgery. Methods 116 ICU patients with severe cerebral hemorrhage treated in Taian Maternal and Child Health Hospital from June 2018 to June 2020 were selected as the research objects and randomly divided into the control group and experimental group, with 58 patients in each group. The control group was given routine treatment, while the experimental group was additionally given an intravenous drip of cinepazide maleate to compare the clinical efficacy and serum inflammatory factors between the two groups. Results The total effective rate in the experimental group was higher than that in the control group (P < 0.05). After treatment, the Glasgow Coma Scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and Fugl-Meyer scores in both groups were better than those before treatment, and the scores in the experimental group were better than those in the control group (P < 0.05). The oxidative stress indexes such as total antioxidant capacity (T-Aoc), superoxide dismutase (SOD), and glutathione peroxidase (GSH-PX) in the experimental group were higher than those in the control group, while malondialdehyde (MDA) in the experimental group was lower than that in the control group (P < 0.05). The high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) levels in the experimental group were lower than those in the control group (P < 0.05). Compared with the control group, the cerebrovascular function in the experimental group was significantly improved (P < 0.05), with statistically significant differences. Conclusion Cinepazide maleate can effectively reduce the serum inflammatory factor levels of ICU patients with severe cerebral hemorrhage after surgery, alleviate the oxidative stress response in the body, and improve the cerebrovascular function and cerebral nerve function, which is worthy of clinical promotion.
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Effect of Holistic Nursing Intervention Combined with Humanized Nursing Intervention on Activities of Daily Living and Limb Movement Ability of Elderly Patients with Cerebral Hemorrhage after Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:2480551. [PMID: 34721623 PMCID: PMC8556103 DOI: 10.1155/2021/2480551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022]
Abstract
Background To improve the nursing status, activities of daily living (ADL), and limb movement ability of elderly patients with cerebral hemorrhage and to actively explore the comprehensive nursing mode that can meet the rehabilitation needs of patients. Methods 128 elderly patients with cerebral hemorrhage admitted to our department (2019.01–2021.01) were included in the study and randomly divided into the reference group and the study group according to the numeration table, with 64 cases in each group. The reference group received routine nursing, while the study group received holistic nursing combined with humanized nursing. Statistical methods were used to analyze the nursing effect of the two intervention models. Results With better scores of the upper limb muscle strength, lower limb muscle strength, and total Fugl-Meyer Assessment (FMA) in both groups after nursing, the scores in the study group after nursing were higher than those in the reference group (P < 0.05). After nursing, the ADL scores of both groups were significantly improved and the score in the study group was better than that in the reference group (P < 0.05). After nursing, the degree of neurological deficit in both groups was significantly better than that before nursing and the degree in the reference group was more serious than that in the study group (P < 0.05). Compared with the reference group, the total infection rate in the study group was lower, while the nursing satisfaction was higher, with statistical significance (P < 0.05). Conclusion The holistic nursing combined with humanized nursing has a remarkable effect on the postoperative intervention of elderly patients with cerebral hemorrhage. It can improve the limb movement function, enhance the ADL, reduce the degree of neurological deficit, improve the quality of life, and enhance the nursing satisfaction of patients after intervention, which is worthy of clinical popularization.
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Abstract
Intracranial vascular abnormalities rarely are encountered in primary care. Many of the pathologies are occult and prognosis varies widely between inconsequential variants of anatomy to acutely life-threatening conditions. Consequently, there often is a great deal of anxiety associated with any potential diagnosis. This article reviews anatomic intracranial vascular lesions, including vascular malformations (arteriovenous malformations/arteriovenous fistulae and cavernous malformations), structural arteriopathies (aneurysms and moyamoya), and common developmental anomalies of the vasculature. The focus includes a general overview of anatomy, pathology, epidemiology, and key aspects of evaluation for the primary care provider and a review of common questions encountered in practice.
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Steinberg JA, Brandel MG, Kang KM, Rennert RC, Pannell JS, Olson SE, Gonda DD, Khalessi AA, Levy ML. Arteriovenous malformation surgery in children: the Rady Children's Hospital experience (2002-2019). Childs Nerv Syst 2021; 37:1267-1277. [PMID: 33404725 DOI: 10.1007/s00381-020-04994-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Compared to adult AVMs, there is a paucity of data on the microsurgical treatment of pediatric AVMs. We report our institutional experience with pediatric AVMs treated by microsurgical resection with or without endovascular embolization and radiation therapy. METHODS We retrospectively reviewed all patients ≤ 18 years of age with cerebral AVMs that underwent microsurgical resection at Rady Children's Hospital 2002-2019. RESULTS Eighty-nine patients met inclusion criteria. The mean age was 10.3 ± 5.0 years, and 56% of patients were male. In total, 72 (81%) patients presented with rupture. Patients with unruptured AVMs presented with headache (n = 5, 29.4%), seizure (n = 9, 52.9%), or incidental finding (n = 3, 17.7%). The mean presenting mRS was 2.8 ± 1.8. AVM location was lobar in 78%, cerebellar/brainstem in 15%, and deep supratentorial in 8%. Spetzler-Martin grade was I in 28%, II in 45%, III in 20%, IV in 6%, and V in 1%. Preoperative embolization was utilized in 38% of patients and more frequently in unruptured than ruptured AVMs (62% vs. 32%, p = 0.022). Radiographic obliteration was achieved in 76/89 (85.4%) patients. Complications occurred in 7 (8%) patients. Annualized rates of delayed rebleeding and recurrence were 1.2% and 0.9%, respectively. The mean follow-up was 2.8 ± 3.1 years. A good neurological outcome (mRS score ≤ 2) was obtained in 80.9% of patients at last follow-up and was improved relative to presentation for 75% of patients. CONCLUSIONS Our case series demonstrates high rates of radiographic obliteration and relatively low incidence of neurologic complications of treatment or AVM recurrence.
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Affiliation(s)
- Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - David D Gonda
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA. .,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
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Zhang XR, Zhang T, Huard LL, Villablanca JP, Vinters HV. Fatal intracranial hemorrhage from brain AVM in a 7-week-old infant: case report and recent literature review. Childs Nerv Syst 2020; 36:1563-1568. [PMID: 31974663 DOI: 10.1007/s00381-020-04515-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/12/2020] [Indexed: 12/21/2022]
Abstract
Brain arteriovenous malformations (AVMs) are vascular abnormalities that typically present with spontaneous hemorrhage, seizure, or as a mass lesion. Pediatric brain AVMs are rarely diagnosed but carry a higher rate of rupture. We report a 7-week-old infant with rapid fatal intracranial hemorrhage from an undiagnosed brain. AVM confirmed at autopsy. Literature review on pediatric patients who had acute death caused by previously undiagnosed brain AVM from 1992 to 2018 revealed that cerebellum is the most frequent location of such AVMs, followed by thalamus. All the children had extensive intracranial hemorrhage that led to their deterioration despite surgical intervention.
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Affiliation(s)
- Xinhai Robert Zhang
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Pathology, Rush University Medical Center, Chicago, IL, USA
| | - Ting Zhang
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Leanna L Huard
- Department of Pediatrics, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - J Pablo Villablanca
- Department of Radiological Science, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Harry V Vinters
- Section of Neuropathology, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Panagopoulos D, Markogiannakis G, Themistocleous M. Ruptured Arteriovenous Malformation Anterior to the Brainstem to a Child with Subsequent Spontaneous Thrombosis: Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923289. [PMID: 32355154 PMCID: PMC7213815 DOI: 10.12659/ajcr.923289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) are considered to be abnormalities of congenital origin, presumably arising due to a disorder in the process of embryogenesis, in the phase of differentiation of premature vascular domes into mature arteries, capillaries, and veins. The end result of that process is the formation of direct arteriovenous communications, without intervening capillary beds. CASE REPORT We report the case of a 6-year-old female who suffered an abrupt deterioration of her level of consciousness due to a subarachnoid hemorrhage located in the basal cisterns. Radiological investigation with magnetic resonance arteriography-magnetic resonance venography (MRA-MRV) was negative, but digital subtraction angiography (DSA) revealed a micro-AVM in the vicinity of the brainstem. The patient subsequently developed communicating hydrocephalus and the repeat DSA, performed 1 month later, failed to re-imagine the lesion. Further workup with DSA 1 year after the ictus was negative for pathological findings. CONCLUSIONS There are a lot of controversies regarding the optimal imaging modality for surveillance of pediatric AVMs, the time period needed to follow-up a given lesion, even if it is considered treated, and the underlying mechanism of spontaneous thrombosis of untreated, yet ruptured, AVMs. All these issues, along with the unusual mode of evolution of the clinical picture of this lesion are discussed in detail, along with a review of the available literature.
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Affiliation(s)
| | | | - Marios Themistocleous
- Department of Neurosurgery, Pediatric Hospital of Athens, Agia Sophia, Athens, Greece
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Ravindra VM, Karsy M, Lanpher A, Bollo RJ, Griauzde J, Scott RM, Couldwell WT, Smith ER. A national analysis of 9655 pediatric cerebrovascular malformations: effect of hospital volume on outcomes. J Neurosurg Pediatr 2019; 24:397-406. [PMID: 31374543 DOI: 10.3171/2019.5.peds19155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Comprehensive multicenter data on the surgical treatment of pediatric cerebrovascular malformations (CVMs) in the US are lacking. The goal of this study was to identify national trends in patient demographics and assess the effect of hospital case volume on outcomes. METHODS Admissions for CVMs (1997-2012) were identified from the nationwide Kids' Inpatient Database. Admissions with and without craniotomy were reviewed separately. Patients were categorized by whether they were treated at low-, medium-, or high-volume centers (< 10, 10-40, > 40 cases/year, respectively). A generalized linear model was used to evaluate the association of hospital pediatric CVM case volume and clinical variables assessing outcomes. RESULTS Among the 9655 patients, 1828 underwent craniotomy and 7827 did not. Patient age and race differed in the two groups, as did the rate of private medical payers. High-volume hospitals had fewer nonroutine discharges (11.2% [high] vs 16.4% [medium] vs 22.3% [low], p = 0.0001). For admissions requiring craniotomy, total charges ($106,282 [high] vs $126,215 [medium] vs $134,978 [low], p < 0.001) and complication rates (0.09% [high] vs 0.11% [medium] vs 0.16% [low], p = 0.001) were lower in high-volume centers. CONCLUSIONS This study revealed that further investigation may be needed regarding barriers to surgical treatment of pediatric CVMs. The authors found that surgical treatment of pediatric CVM at high-volume centers is associated with significantly fewer complications, better dispositions, and lower costs, but for noncraniotomy patients, low-volume centers had lower rates of complications and death and lower costs. These findings may support the consideration of appropriate referral of CVM patients requiring surgery or with intracranial hemorrhage toward high-volume, specialized centers.
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Affiliation(s)
- Vijay M Ravindra
- 1Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Michael Karsy
- 1Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | - Robert J Bollo
- 1Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Julius Griauzde
- 4Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - R Michael Scott
- 2Department of Neurosurgery, Children's Hospital Boston
- 3Department of Neurosurgery, Harvard Medical School, Harvard University, Cambridge, Massachusetts; and
| | | | - Edward R Smith
- 2Department of Neurosurgery, Children's Hospital Boston
- 3Department of Neurosurgery, Harvard Medical School, Harvard University, Cambridge, Massachusetts; and
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