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De Vlieger G, Meyfroidt G. Kidney Dysfunction After Traumatic Brain Injury: Pathophysiology and General Management. Neurocrit Care 2023; 38:504-516. [PMID: 36324003 PMCID: PMC9629888 DOI: 10.1007/s12028-022-01630-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) remains a major cause of mortality and morbidity, and almost half of these patients are admitted to the intensive care unit. Of those, 10% develop acute kidney injury (AKI) and 2% even need kidney replacement therapy (KRT). Although clinical trials in patients with TBI who have AKI are lacking, some general principles in this population may apply. The present review is an overview on the epidemiology and pathophysiology of AKI in patients with TBI admitted to the intensive care unit who are at risk for or who have developed AKI. A cornerstone in severe TBI management is preventing secondary brain damage, in which reducing the intracranial pressure (ICP) and optimizing the cerebral perfusion pressure (CPP) remain important therapeutic targets. To treat episodes of elevated ICP, osmolar agents such as mannitol and hypertonic saline are frequently administered. Although we are currently awaiting the results of a prospective randomized controlled trial that compares both agents, it is important to realize that both agents have been associated with an increased risk of developing AKI which is probably higher for mannitol compared with hypertonic saline. For the brain, as well as for the kidney, targeting an adequate perfusion pressure is important. Hemodynamic management based on the combined use of intravascular fluids and vasopressors is ideally guided by hemodynamic monitoring. Hypotonic albumin or crystalloid resuscitation solutions may increase the risk of brain edema, and saline-based solutions are frequently used but have a risk of hyperchloremia, which might jeopardize kidney function. In patients at risk, frequent assessment of serum chloride might be advised. Maintenance of an adequate CPP involves the optimization of circulating blood volume, often combined with vasopressor agents. Whether individualized CPP targets based on cerebrovascular autoregulation monitoring are beneficial need to be further investigated. Interestingly, such individualized perfusion targets are also under investigation in patients as a strategy to mitigate the risk for AKI in patients with chronic hypertension. In the small proportion of patients with TBI who need KRT, continuous techniques are advised based on pathophysiology and expert opinion. The need for KRT is associated with a higher risk of intracranial hypertension, especially if osmolar clearance occurs fast, which can even occur in continuous techniques. Precise ICP and CPP monitoring is mandatory, especially at the initiation of KRT.
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Affiliation(s)
- Greet De Vlieger
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Geert Meyfroidt
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Fractional Gluconeogenesis: A Biomarker of Dietary Energy Adequacy in a Rat Brain Injury Model. Metabolites 2022; 12:metabo12121163. [PMID: 36557201 PMCID: PMC9781857 DOI: 10.3390/metabo12121163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Patients treated for traumatic brain injury (TBI) are in metabolic crises because of the trauma and underfeeding. We utilized fractional gluconeogenesis (fGNG) to assess nutritional adequacy in ad libitum-fed and calorically-restricted rats following TBI. Male Sprague-Dawley individually housed rats 49 days of age were randomly assigned into four groups: ad libitum (AL) fed control (AL-Con, sham), AL plus TBI (AL+TBI), caloric restriction (CR) control (CR-Con, sham), and CR plus TBI (CR+TBI). From days 1-7 animals were given AL access to food and water containing 6% deuterium oxide (D2O). On day 8, a pre-intervention blood sample was drawn from each animal, and TBI, sham injury, and CR protocols were initiated. On day 22, the animals were euthanized, and blood was collected to measure fGNG. Pre-intervention, there was no significant difference in fGNG among groups (p ≥ 0.05). There was a significant increase in fGNG due to caloric restriction, independent of TBI (p ≤ 0.05). In addition, fGNG may provide a real-time, personalized biomarker for assessing patient dietary caloric needs.
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Vázquez-Lorente H, Herrera-Quintana L, Molina-López J, Zapata-Soria M, Planells E. Need of nutritional assessment and monitoring in a population with acquired brain injury: an analytical cross-sectional study. Nutr Neurosci 2022; 26:525-534. [PMID: 35499860 DOI: 10.1080/1028415x.2022.2065815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patients with acquired brain injury (ABI) may be at an increased risk of malnutrition due to the pathophysiology of their condition, which can affect their anthropometrical profile and therefore their quality of life. The present study analyzes the anthropometrical profile of these individuals, describes their dietary habits and nutrients intake and identifies the related risk factors influencing health status and quality of life. METHODS Twenty-three volunteers with ABI from the province of Granada (Spain) were recruited for this cross-sectional study. Nutritional assessment was quantitatively and qualitatively performed using a 72-h dietary record and a food frequency questionnaire, respectively. Body composition parameters were evaluated by bioelectrical impedance. RESULTS Low intakes of minerals related to bone health, extra virgin olive oil (EVOO) and fruits were reported. Moreover, women presented a poorer anthropometrical profile compared to men. With reference to age, a significant inverse correlation was observed with sarcopenic obesity, appendicular muscle mass index and Vitamin B6 intake [(r = -0.617, p < 0.01), (r = -0.475, p < 0.05) and (r = -0.498, p < 0.05), respectively]. Intake of EVOO was inversely correlated to body mass index (r = -0.767, p < 0.001). Lastly, a direct correlation was observed between the consumption of alcohol and sweets and snacks (r = 0.608, p < 0.01). CONCLUSION The main findings support the existence of poor dietary quality and anthropometrical profile. Interdisciplinary team assessment would be beneficial to enhance the quality of life and attenuate the development of comorbidities in subjects with ABI.
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Affiliation(s)
- H. Vázquez-Lorente
- Department of Physiology, School of Pharmacy, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Granada, Spain
| | - L. Herrera-Quintana
- Department of Physiology, School of Pharmacy, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Granada, Spain
| | - J. Molina-López
- Faculty of Education, Psychology and Sports Sciences, University of Huelva, Huelva, Spain
| | - M. Zapata-Soria
- Department of Physiology, School of Pharmacy, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Granada, Spain
- Brain Damage Association (AGREDACE), Granada, Spain
| | - E. Planells
- Department of Physiology, School of Pharmacy, Institute of Nutrition and Food Technology “José Mataix”, University of Granada, Granada, Spain
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Dickerman R, Reynolds A, Williamson J, Winters K. Letter: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 81:E50. [DOI: 10.1093/neuros/nyx308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80:6-15. [PMID: 27654000 DOI: 10.1227/neu.0000000000001432] [Citation(s) in RCA: 1927] [Impact Index Per Article: 275.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/14/2016] [Indexed: 12/13/2022] Open
Abstract
The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.
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Affiliation(s)
- Nancy Carney
- Oregon Health & Science University, Portland, Oregon
| | | | | | - Jamie S Ullman
- Hofstra North Shore-LIJ School of Medicine, Hempstead, New York
| | | | | | | | | | | | - Niranjan Kissoon
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andres M Rubiano
- El Bosque University, Bogota, Colombia
- MEDITECH Foundation, Neiva, Colombia
| | - Lori Shutter
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Harvard Medical School & Boston Children's Hospital, Boston, Massachusetts
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Japanese Guidelines for Nutrition Support Therapy in the Adult and Pediatric Critically Ill Patients: Disease-Specific Nutrition Support Therapy. ACTA ACUST UNITED AC 2017. [DOI: 10.3918/jsicm.24_569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mazaherpur S, Khatony A, Abdi A, Pasdar Y, Najafi F. The Effect of Continuous Enteral Nutrition on Nutrition Indices, Compared to the Intermittent and Combination Enteral Nutrition in Traumatic Brain Injury Patients. J Clin Diagn Res 2016; 10:JC01-JC05. [PMID: 27891355 PMCID: PMC5121693 DOI: 10.7860/jcdr/2016/19271.8625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/17/2016] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Nutrition support is one of the most common care, which is undertaken for patients who suffered from Traumatic Brain Injury (TBI) and are admitted in intensive care units. Literature indicates some controversies regarding the appropriate method of nutrition support in these patients. AIM This study was conducted for determining the effect of continuous enteral nutrition on nutrition indices, compared to the intermittent enteral and combination nutrition in TBI patients. MATERIALS AND METHODS In a randomized clinical trial, 60 TBI patients who were admitted to critical care units of Taleghani Hospital of Kermanshah-Iran in 2010 recruited to the study. The samples were allocated to three groups of continuous enteral nutrition, intermittent enteral nutrition and combination nutrition supports by random sampling. The tool was a researcher-made checklist. The three methods of nutrition support were performed to the participants, then nutrition indices of patients were measured before and during three weeks. Data were analysed using SPSS software, descriptive, and inferential statistics. RESULTS The mean of received energy in the combination group (53.1± 18.3%) was higher than continuous (38.5±19.7%) and intermittent (32.2±14.7%) groups, significantly (p<0.001). The received protein was also greater in combination method (67.7±16.9%) than continuous (31.8±15.1%) and intermittent groups (17.2±10.1%), (p=0.001). The mean of nitrogen balance was improved in continuous method from -4.7± -1.6 to 7.2±5.2, (p<0.001) significantly. CONCLUSION In this study, received energy of patients was not enough by three methods. However, the continuous method, having a positive effect on nitrogen balance, reducing hypercatabolism and maintaining the total body protein, was preferred to brain injury patients compared with intermittent enteral and parenteral methods that demand more studies.
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Affiliation(s)
- Sakine Mazaherpur
- MSc of Critical Care Nursing, Nursing Department, Faculty of Nursing & Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Khatony
- Associate Professor in Nursing Education, Nursing Department, Faculty of Nursing & Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Abdi
- PhD of Nursing, Nursing Department, Faculty of Nursing & Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yahia Pasdar
- Assistant Professor in Nutrition Science, Nutrition Department, Public Health College, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Farid Najafi
- Professor in Epidemiology, Statistics and Epidemiology Department, Research and Technology center, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Dange RB, Agarwal D, Teruyama R, Francis J. Toll-like receptor 4 inhibition within the paraventricular nucleus attenuates blood pressure and inflammatory response in a genetic model of hypertension. J Neuroinflammation 2015; 12:31. [PMID: 25879545 PMCID: PMC4337244 DOI: 10.1186/s12974-015-0242-7] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/10/2015] [Indexed: 02/06/2023] Open
Abstract
Background Despite the availability of several antihypertensive medications, the morbidity and mortality caused by hypertension is on the rise, suggesting the need for investigation of novel signaling pathways involved in its pathogenesis. Recent evidence suggests the role of toll-like receptor (TLR) 4 in various inflammatory diseases, including hypertension. The role of the brain in the initiation and progression of all forms of hypertension is well established, but the role of brain TLR4 in progression of hypertension has never been explored. Therefore, we investigated the role of TLR4 within the paraventricular nucleus (PVN; an important cardioregulatory center in the brain) in an animal model of human essential hypertension. We hypothesized that a TLR4 blockade within the PVN causes a reduction in mean arterial blood pressure (MAP), inflammatory cytokines and sympathetic drive in hypertensive animals. Methods Spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto (WKY) rats were administered either a specific TLR4 blocker, viral inhibitory peptide (VIPER), or control peptide in their PVN for 14 days. MAP was recorded continuously by radiotelemetry. PVN and blood were collected for the measurement of pro-inflammatory cytokines (Tumor Necrosis Factor (TNF)-α, interleukin (IL)-1β), anti-inflammatory cytokine IL-10, inducible nitric oxide synthase (iNOS), TLR4, nuclear factor (NF) κB activity and plasma norepinephrine (NE) and high mobility group box (HMGB)1 expression, respectively. Results Hypertensive rats exhibited significantly higher levels of TLR4 in the PVN. TLR4 inhibition within the PVN attenuated MAP, improved cardiac hypertrophy, reduced TNF-α, IL-1β, iNOS levels, and NFκB activity in SHR but not in WKY rats. These results were associated with a reduction in plasma NE and HMGB1 levels and an increase in IL-10 levels in SHR. Conclusions This study demonstrates that TLR4 upregulation in PVN plays an important role in hypertensive response. Our results provide mechanistic evidence that hypertensive response in SHR are mediated, at least in part, by TLR4 in the PVN and that inhibition of TLR4 within the PVN attenuates blood pressure and improves inflammation, possibly via reduction in sympathetic activity.
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Affiliation(s)
- Rahul B Dange
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA.
| | - Deepmala Agarwal
- William Hansel Cancer Prevention Laboratory, Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808, USA.
| | - Ryoichi Teruyama
- Department of Biological Sciences, College of Science, Louisiana State University, 202 Life Sciences Building, Baton Rouge, LA, 70803, USA.
| | - Joseph Francis
- Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA.
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Nutrition therapy in the optimisation of health outcomes in adult patients with moderate to severe traumatic brain injury: findings from a scoping review. Injury 2014; 45:1834-41. [PMID: 24996574 DOI: 10.1016/j.injury.2014.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 06/04/2014] [Accepted: 06/06/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients who have sustained traumatic brain injury (TBI) have increased nutritional requirements yet are often unable to eat normally, and adequate nutritional therapy is needed to optimise recovery. The aim of the current scoping review was to describe the existing evidence for improved outcomes with optimal nutrition therapy in adult patients with moderate to severe TBI, and to identify gaps in the literature to inform future research. METHODS Using an exploratory scoping study approach, Medline, Cinahl, Embase, CENTRAL, the Neurotrauma reviews in the Global Evidence Mapping (GEM) Initiative, and Evidence Reviews in Acquired Brain Injury (ERABI) were searched from 2003 to 14 November 2013 using variations of the search terms 'traumatic brain injury' and 'nutrition'. Articles were included if they reported mortality, morbidity, or length of stay outcomes, and were classified according to the nature of nutrition intervention and study design. RESULTS Twenty relevant articles were identified of which: 12 were original research articles; two were systematic reviews; one a meta-analysis; and five were narrative reviews. Of these, eleven explored timing of feed provision, eight explored route of administration of feeding, nine examined the provision of specific nutrients, and none examined feeding environment. Some explored more than one intervention. Three sets of guidelines which contain feeding recommendations were also identified. DISCUSSION Inconsistency within nutrition intervention methods and outcome measures means that the present evidence base is inadequate for the construction of best practice guidelines for nutrition and TBI. Further research is necessary to elucidate the optimal nutrition therapy for adults with TBI with respect to the timing, route of administration, nutrient provision and feeding environment. A consensus on the ideal outcome measure and the most appropriate method and timing of its measurement is required as a foundation for this evidence base.
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Dange RB, Agarwal D, Masson GS, Vila J, Wilson B, Nair A, Francis J. Central blockade of TLR4 improves cardiac function and attenuates myocardial inflammation in angiotensin II-induced hypertension. Cardiovasc Res 2014; 103:17-27. [DOI: 10.1093/cvr/cvu067] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wang X, Dong Y, Han X, Qi XQ, Huang CG, Hou LJ. Nutritional support for patients sustaining traumatic brain injury: a systematic review and meta-analysis of prospective studies. PLoS One 2013; 8:e58838. [PMID: 23527035 PMCID: PMC3602547 DOI: 10.1371/journal.pone.0058838] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/07/2013] [Indexed: 01/13/2023] Open
Abstract
Background In traumatic brain injury (TBI), the appropriate timing and route of feeding, and the efficacy of immune-enhancing formulae have not been well established. We performed this meta-analysis aiming to compare the effects of different nutritional support modalities on clinical outcomes of TBI patients. Methods We systematically searched Pubmed, Embase, and the Cochrane Library until October, 2012. All randomized controlled trials (RCTs) and non-randomized prospective studies (NPSs) that compared the effects of different routes, timings, or formulae of feeding on outcomes in TBI patients were selected. The primary outcomes included mortality and poor outcome. The secondary outcomes included the length of hospital stay, the length of ventilation days, and the rate of infectious or feeding-related complications. Findings 13 RCTs and 3 NPSs were included. The pooled data demonstrated that, compared with delayed feeding, early feeding was associated with a significant reduction in the rate of mortality (relative risk [RR] = 0.35; 95% CI, 0.24–0.50), poor outcome (RR = 0.70; 95% CI, 0.54–0.91), and infectious complications (RR = 0.77; 95% CI, 0.59–0.99). Compared with enteral nutrition, parenteral nutrition showed a slight trend of reduction in the rate of mortality (RR = 0.61; 95% CI, 0.34–1.09), poor outcome (RR = 0.73; 95% CI, 0.51–1.04), and infectious complications (RR = 0.89; 95% CI, 0.66–1.22), whereas without statistical significances. The immune-enhancing formula was associated with a significant reduction in infection rate compared with the standard formula (RR = 0.54; 95% CI, 0.35–0.82). Small-bowel feeding was found to be with a decreasing rate of pneumonia compared with nasogastric feeding (RR = 0.41; 95% CI, 0.22–0.76). Conclusion After TBI, early initiation of nutrition is recommended. It appears that parenteral nutrition is superior to enteral nutrition in improving outcomes. Our results lend support to the use of small-bowel feeding and immune-enhancing formulae in reducing infectious complications.
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Affiliation(s)
- Xiang Wang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yan Dong
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
- Neuroscience Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xi Han
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiang-Qian Qi
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Cheng-Guang Huang
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (LJH); (CGH)
| | - Li-Jun Hou
- Department of Neurosurgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
- * E-mail: (LJH); (CGH)
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