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Idrees M, Taimuri MA, Azhar A, Khan NA, Kalsoom U, Sajid A, Akilimali A. Deep brain stimulation for post-stroke rehabilitation in Pakistan. Ann Med Surg (Lond) 2024; 86:5966-5972. [PMID: 39359821 PMCID: PMC11444625 DOI: 10.1097/ms9.0000000000002511] [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: 04/03/2024] [Accepted: 08/16/2024] [Indexed: 10/04/2024] Open
Abstract
Stroke has a high prevalence in Pakistan, at an alarming rate of 250 per 100 000 people. Although various treatment options are available, they are not ideal for Pakistan due to their high cost, restricted availability, and time sensitivity. In 1997, the FDA-approved deep brain stimulation (DBS) for Parkinson's disease and it was first performed in Pakistan in 2014. DBS has also proved effective for restoring post-stroke mobility, according to a trial from August 2023. DBS has the potential to revolutionize post-stroke rehabilitation in Pakistan; however, further research is required into its effectiveness and its limitations must be addressed first.
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Affiliation(s)
| | - Muskan A Taimuri
- Department of Internal Medicine, Dow University of Health Sciences
| | - Ayesha Azhar
- Department of Internal Medicine, Dow University of Health Sciences
| | - Najam A Khan
- Department of Internal Medicine, Dow University of Health Sciences
| | | | - Aiman Sajid
- Sir Syed College of Medical Sciences, Karachi
| | - Aymar Akilimali
- Department of Research, Medical Research Circle, Goma, DR Congo
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Yuan X, Hu S, Fan X, Jiang C, Xu Y, Hao R, Xu Z, Yu Y, Rastegar-Kashkooli Y, Huang L, Wang TJ, Wang Q, Su S, Wang L, Wang J, Wang M, Kim YT, Bhawal UK, Wang F, Zhao T, Wang J, Chen X, Wang J. Central post-stroke pain: advances in clinical and preclinical research. Stroke Vasc Neurol 2024:svn-2024-003418. [PMID: 39343438 DOI: 10.1136/svn-2024-003418] [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: 05/22/2024] [Accepted: 09/04/2024] [Indexed: 10/01/2024] Open
Abstract
Central poststroke pain (CPSP) is a medical complication that arises poststroke and significantly impacts the quality of life and social functioning of affected individuals. Despite ongoing research, the exact pathomechanisms of CPSP remain unclear, and practical treatments are still unavailable. Our review aims to systematically analyse current clinical and preclinical studies on CPSP, which is critical for identifying gaps in knowledge and guiding the development of effective therapies. The review will clarify the clinical characteristics, evaluation scales and contemporary therapeutic approaches for CPSP based on clinical investigations. It will particularly emphasise the CPSP model initiated by stroke, shedding light on its underlying mechanisms and evaluating treatments validated in preclinical studies. Furthermore, the review will not only highlight methodological limitations in animal trials but also offer specific recommendations to researchers to improve the quality of future investigations and guide the development of effective therapies. This review is expected to provide valuable insights into the current knowledge regarding CPSP and can serve as a guide for future research and clinical practice. The review will contribute to the scientific understanding of CPSP and help develop effective clinical interventions.
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Affiliation(s)
- Xiqian Yuan
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Siyuan Hu
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaochong Fan
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Chao Jiang
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yan Xu
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Ruochen Hao
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Zili Xu
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Yiyang Yu
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Yousef Rastegar-Kashkooli
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
- School of International Education, Zhengzhou University, Zhengzhou, Henan, China
| | - Leo Huang
- Department of Psychology, University of Toronto, Toronto, Ontario, Canada
| | - Tom J Wang
- Program in Behavioral Biology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Qiao Wang
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Songxue Su
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Limin Wang
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Junyang Wang
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Menglu Wang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Yun Tai Kim
- Division of Functional Food Research, Korea Food Research Institute, Wanju-gun, Wanju Jeollabuk-do, Korea (the Republic of)
- Department of Food Biotechnology, Korea University of Science & Technology, Daejeon, Korea (the Republic of)
| | - Ujjal K Bhawal
- Center for Global Health Research, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil nadu, India
- Research Institute of Oral Science, Nihon University School of Dentistry at Matsudo, Chiba, Japan
| | - Fushun Wang
- Department of Psychology, Sichuan Normal University, Chengdu, Sichuan, China
| | - Ting Zhao
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junmin Wang
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Xuemei Chen
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Jian Wang
- Department of Pain Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Human Anatomy, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan, China
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Huang Y, Sadeghzadeh S, Li AHY, Schonfeld E, Ramayya AG, Buch VP. Rates and Predictors of Pain Reduction With Intracranial Stimulation for Intractable Pain Disorders. Neurosurgery 2024:00006123-990000000-01186. [PMID: 38836613 DOI: 10.1227/neu.0000000000003006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial modulation paradigms, namely deep brain stimulation (DBS) and motor cortex stimulation (MCS), have been used to treat intractable pain disorders. However, treatment efficacy remains heterogeneous, and factors associated with pain reduction are not completely understood. METHODS We performed an individual patient review of pain outcomes (visual analog scale, quality-of-life measures, complications, pulse generator implant rate, cessation of stimulation) after implantation of DBS or MCS devices. We evaluated 663 patients from 36 study groups and stratified outcomes by pain etiology and implantation targets. RESULTS Included studies comprised primarily retrospective cohort studies. MCS patients had a similar externalized trial success rate compared with DBS patients (86% vs 81%; P = .16), whereas patients with peripheral pain had a higher trial success rate compared with patients with central pain (88% vs 79%; P = .004). Complication rates were similar for MCS and DBS patients (12% vs 15%; P = .79). Patients with peripheral pain had lower likelihood of device cessation compared with those with central pain (5.7% vs 10%; P = .03). Of all implanted patients, mean pain reduction at last follow-up was 45.8% (95% CI: 40.3-51.2) with a 31.2% (95% CI: 12.4-50.1) improvement in quality of life. No difference was seen between MCS patients (43.8%; 95% CI: 36.7-58.2) and DBS patients (48.6%; 95% CI: 39.2-58) or central (41.5%; 95% CI: 34.8-48.2) and peripheral (46.7%; 95% CI: 38.9-54.5) etiologies. Multivariate analysis identified the anterior cingulate cortex target to be associated with worse pain reduction, while postherpetic neuralgia was a positive prognostic factor. CONCLUSION Both DBS and MCS have similar efficacy and complication rates in the treatment of intractable pain. Patients with central pain disorders tended to have lower trial success and higher rates of device cessation. Additional prognostic factors include anterior cingulate cortex targeting and postherpetic neuralgia diagnosis. These findings underscore intracranial neurostimulation as an important modality for treatment of intractable pain disorders.
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Affiliation(s)
- Yuhao Huang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Alice Huai-Yu Li
- Department of Anesthesia, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ethan Schonfeld
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ashwin G Ramayya
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vivek P Buch
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
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Baek H, Chen J, Lockwood D, Obusez E, Poturalski M, Nagel SJ, Jones SE. Feasibility of Magnetic Resonance-Compatible Accelerometers to Monitor Tremor Fluctuations During Magnetic Resonance-Guided Focused Ultrasound Thalamotomy: Technical Note. Oper Neurosurg (Hagerstown) 2023; 24:641-650. [PMID: 36827201 DOI: 10.1227/ons.0000000000000638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/30/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is used to treat essential tremor and tremor-dominant Parkinson disease. Feedback is collected throughout the procedure to verify the location of the target and completeness of response; however, variability in clinical judgments may underestimate or overestimate treatment response. OBJECTIVE To objectively quantify joint motion after each sonication using accelerometers secured to the contralateral upper extremity in an effort to optimize MRgFUS treatment. METHODS Before the procedure, 3 accelerometers were secured to the patient's arm, forearm, and index finger. Throughout the procedure, tremor motion was regularly recorded during postural and kinetic tremor testing and individual joint angle measures were modeled. The joint angle from each accelerometer was compared with baseline measurements to assess changes in angles. Subsequent adjustments to the target location and sonication energy were made at the discretion of the neurosurgeon and neuroradiologist. RESULTS Intraoperative accelerometer measurements of hand tremor from 18 patients provided quantified data regarding joint angle reduction: 87.3%, 94.2%, and 86.7% for signature writing, spiral drawing, and line drawing tests, respectively. Target adjustment based on accelerometer monitoring of the angle at each joint added substantial value toward achieving optimal tremor reduction. CONCLUSION Real-time accelerometer recordings collected during MRgFUS thalamotomy offered objective quantification of changes in joint angle after each sonication, and these findings were consistent with clinical judgments of tremor response. These results suggest that this technique could be used for fine adjustment of the location of sonication energy and number of sonications to consistently achieve optimal tremor reduction.
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Affiliation(s)
- Hongchae Baek
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | | | | | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Quantitative and Fiber-Selective Evaluation for Central Poststroke Pain. Neural Plast 2022; 2022:1507291. [PMID: 35707518 PMCID: PMC9192306 DOI: 10.1155/2022/1507291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/24/2022] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
The electrophysiological recording can be used to quantify the clinical features of central poststroke pain (CPSP) caused by different lesion locations. We aimed to explore the relationship between clinical features and lesion location in patients with CPSP using the current perception threshold (CPT) approach. Here, patients underwent the standardized CPT measure at five detection sites on both the contralesional and ipsilesional sides, using a constant alternating-current sinusoid waveform stimulus at three frequencies: 2000 Hz, 250 Hz, and 5 Hz. 57 CPSP patients were recruited in this cross-sectional study, including 13 patients with thalamic lesions and 44 patients with internal capsule lesions. Patients with a thalamic lesion had more frequent abnormal Aδ and C fibers than those with an internal capsule lesion (69.2% versus 36.4%, p value = 0.038; 53.8% versus 63.6%, p value = 0.038). The patients with internal capsule lesions had more frequent abnormal Aβ fibers than those with thalamic lesions (53.8% versus 63.6%, p value < 0.001). The sensory dysfunction in the patients with thalamic lesions was more likely to occur in the upper limbs (i.e., the shoulder (p value = 0.027) and the finger (p value = 0.040)). The lower limbs (i.e., the knee (p value = 0.040) and the toe (p value = 0.005)) were more likely to experience sensory dysfunction in the patients with internal capsule lesions. Hyperesthesia was more likely to occur in the thalamic patients, and hypoesthesia was more likely to occur in the patients with internal capsule lesions (p value < 0.001). In patients with thalamic lesions, Visual Analogue Scale (VAS) had a positive correlation with 5 Hz CPT on the shoulder (r = 0.010, p value = 0.005), 250 Hz CPT on the finger (r = 0.690, p value = 0.009) from the contralesional side, and 2000 Hz CPT on the knee (r = 0.690, p value = 0.009). In patients with internal capsule lesions, VAS had a positive correlation with 2000 Hz CPT on the knee (r = 0.312, p value = 0.039) and foot (r = 0.538, p value < 0.001). In conclusion, the abnormal fiber types, sensory dysfunction territory, and clinical signs of CPSP in thalamic stroke differ from those in internal capsule stroke. Implementation of the portable and convenient CPT protocol may help clarify the locations of different stroke lesions in various clinical settings.
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Yamamoto K, Elias GJB, Beyn ME, Zemmar A, Loh A, Sarica C, Germann J, Parmar R, Wong EHY, Boutet A, Kalia S, Hodaie M, Lozano AM. Neuromodulation for Pain: A Comprehensive Survey and Systematic Review of Clinical Trials and Connectomic Analysis of Brain Targets. Stereotact Funct Neurosurg 2021; 100:14-25. [PMID: 34380132 DOI: 10.1159/000517873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/28/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic pain is a debilitating condition that imposes a tremendous burden on health-care systems around the world. While frontline treatments for chronic pain involve pharmacological and psychological approaches, neuromodulation can be considered for treatment-resistant cases. Neuromodulatory approaches for pain are diverse in both modality and target and their mechanism of action is incompletely understood. OBJECTIVES The objectives of this study were to (i) understand the current landscape of pain neuromodulation research through a comprehensive survey of past and current registered clinical trials (ii) investigate the network underpinnings of these neuromodulatory treatments by performing a connectomic mapping analysis of cortical and subcortical brain targets that have been stimulated for pain relief. METHODS A search for clinical trials involving pain neuromodulation was conducted using 2 major trial databases (ClinicalTrials.gov and the International Clinical Trials Registry Platform). Trials were categorized by variables and analyzed to gain an overview of the contemporary research landscape. Additionally, a connectomic mapping analysis was performed to investigate the network connectivity patterns of analgesic brain stimulation targets using a normative connectome based on a functional magnetic resonance imaging dataset. RESULTS In total, 487 relevant clinical trials were identified. Noninvasive cortical stimulation and spinal cord stimulation trials represented 49.3 and 43.7% of this count, respectively, while deep brain stimulation trials accounted for <3%. The mapping analysis revealed that superficial target connectomics overlapped with deep target connectomics, suggesting a common pain network across the targets. CONCLUSIONS Research for pain neuromodulation is a rapidly growing field. Our connectomic network analysis reinforced existing knowledge of the pain matrix, identifying both well-described hubs and more obscure structures. Further studies are needed to decode the circuits underlying pain relief and determine the most effective targets for neuromodulatory treatment.
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Affiliation(s)
- Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada,
| | - Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Michelle E Beyn
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Ajmal Zemmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital, Henan University People's Hospital, Henan University School of Medicine, Zhengzhou, China
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Can Sarica
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Roohie Parmar
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Emily H Y Wong
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Suneil Kalia
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
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Nüssel M, Hamperl M, Maslarova A, Chaudhry SR, Köhn J, Stadlbauer A, Buchfelder M, Kinfe T. Burst Motor Cortex Stimulation Evokes Sustained Suppression of Thalamic Stroke Pain: A Narrative Review and Single-Case Overview. Pain Ther 2020; 10:101-114. [PMID: 33325005 PMCID: PMC8119548 DOI: 10.1007/s40122-020-00221-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic refractory central post-stroke pain (CPSP), one of the most disabling consequences of cerebral stroke, occurs in up to 10% of patients with CPSP. Because a considerable proportion of these patients with chronic pain remain resistant to pharmacological and behavioral therapies, adjunctive invasive and non-invasive brain stimulation therapies are needed. We performed a review of human studies applying burst and conventional motor cortex stimulation (burstMCS and cMCS, respectively) for chronic pain states, on the basis of data sources identified through searches of PubMed, MEDLINE/OVID, and SCOPUS, as well as manual searches of the bibliographies of known primary and review articles. Our aim was to review and discuss clinical data on the indications of burstMCS for various chronic pain states originating from central stroke (excluding trigeminal facial pain). In addition, we assessed the efficacy and safety of burst versus cMCS for central post-stroke pain with an extended follow-up of 5 years in a 60-year-old man. According to our review, uncontrolled observational human cohort studies and one RCT using cMCS waveforms have revealed a meaningful clinical response; however, these studies lacked placebo groups and extended observation periods. In our case report, we found that 3 months of adjunctive cMCS reduced pain levels [visual analog scale (VAS) pre: 9/10 versus VAS post 7/10], whereas the pain decreased further under burstMCS (VAS pre: 7/10 versus VAS post: 2/10); the study involved a follow-up of 5 years and the following parameters: burst rate 40 Hz (500 Hz), 1–1.75 mA, 1 ms, bipolar configuration. To date, only limited evidence exists for the efficacy and safety of burst motor cortex stimulation for the treatment of refractory chronic pain. BurstMCS resulted in significantly decreased post-stroke pain observed after 5 years of cMCS. The available literature suggests similar efficacy as that of conventional (tonic) motor cortex stimulation, although the results are preliminary. Mechanistically, the precise mechanism of action is not fully understood. However, burstMCS may interact with the nociceptive thalamic-cingulate and descending spinal pain networks. To determine the potential utility of this treatment, large-scale sham-controlled trials comparing cMCS and burstMCS are highly recommended.
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Affiliation(s)
- Martin Nüssel
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Melanie Hamperl
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Maslarova
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Shafqat R Chaudhry
- College of Pharmaceutical Sciences, Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Julia Köhn
- Department of Neurology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Stadlbauer
- Institute of Medical Radiology, University Clinic St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Kinfe
- Division of Functional Neurosurgery and Stereotaxy, Friedrich-Alexander University (FAU) Erlangen-Nürnberg, Erlangen, Germany.
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