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Schmutzer-Sondergeld M, Gencer A, Niedermeyer S, Quach S, Stoecklein VM, Teske N, Schichor C, Terpolilli NA, Kunz M, Thon N. Evaluation of surgical treatment strategies and outcome for cerebral arachnoid cysts in children and adults. Acta Neurochir (Wien) 2024; 166:39. [PMID: 38280116 PMCID: PMC10821836 DOI: 10.1007/s00701-024-05950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/30/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVE The best treatment strategies for cerebral arachnoid cysts (CAC) are still up for debate. In this study, we present CAC management, outcome data, and risk factors for recurrence after surgical treatment, focusing on microscopic/endoscopic approaches as compared to minimally invasive stereotactic procedures in children and adults. METHODS In our single-institution retrospective database, we identified all patients treated surgically for newly diagnosed CAC between 2000 and 2022. Microscopic/endoscopic surgery (ME) aimed for safe cyst wall fenestration. Stereotactic implantation of an internal shunt catheter (STX) to drain CAC into the ventricles and/or cisterns was used as an alternative procedure in patients aged ≥ 3 years. Treatment decisions in favor of ME vs. STX were made by interdisciplinary consensus. The primary study endpoint was time to CAC recurrence (TTR). Secondary endpoints were outcome metrics including clinical symptoms and MR-morphological analyses. Data analysis included subdivision of the total cohort into three distinct age groups (AG1, < 6 years; AG2, 6-18 years; AG3, ≥ 18 years). RESULTS Sixty-two patients (median age 26.5 years, range 0-82 years) were analyzed. AG1 included 15, AG2 10, and AG3 37 patients, respectively. The main presenting symptoms were headache and vertigo. In AG1 hygromas, an increase in head circumference and thinning of cranial calvaria were most frequent. Thirty-five patients underwent ME and 27 STX, respectively; frequency did not differ between AGs. There were two (22.2%) periprocedural venous complications in infants (4- and 10-month-old) during an attempt at prepontine fenestration of a complex CAC, one with fatal outcome in a 10-month-old boy. Other complications included postoperative bleeding (2, 22.2%), CSF leaks (4, 44.4%), and meningitis (1, 11.1%). Overall, clinical improvement and significant volume reduction (p = 0.008) were seen in all other patients; this did not differ between AGs. Median follow-up for all patients was 25.4 months (range, 3.1-87.1 months). Recurrent cysts were seen in 16.1%, independent of surgical procedure used (p = 0.7). In cases of recurrence, TTR was 7.9 ± 12.7 months. Preoperative ventricular expansion (p = 0.03), paresis (p = 0.008), and age under 6 years (p = 0.03) were significant risk factors for CAC recurrence in multivariate analysis. CONCLUSIONS In patients suffering from CAC, both ME and STX can improve clinical symptoms at low procedural risk, with equal extent of CAC volume reduction. However, in infants and young children, CAC are more often associated with severe clinical symptoms, stereotactic procedures have limited use, and microsurgery in the posterior fossa may bear the risk of severe venous bleeding.
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Affiliation(s)
| | - Aylin Gencer
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Sebastian Niedermeyer
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Stefanie Quach
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Veit M Stoecklein
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nico Teske
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian Schichor
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nicole Angela Terpolilli
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Mathias Kunz
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, LMU University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Lin X, Khalin I, Harapan BN, Terpolilli NA, Schwarting J, Plesnila N. Perivascular Macrophages Mediate Microvasospasms After Experimental Subarachnoid Hemorrhage. Stroke 2023. [PMID: 37325921 DOI: 10.1161/strokeaha.122.042290] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/16/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is characterized by acute and delayed reductions of cerebral blood flow (CBF) caused, among others, by spasms of cerebral arteries and arterioles. Recently, the inactivation of perivascular macrophages (PVM) has been demonstrated to improve neurological outcomes after experimental SAH, but the underlying mechanisms of protection remain unclear. The aim of our exploratory study was, therefore, to investigate the role of PVM in the formation of acute microvasospasms after experimental SAH. METHODS PVMs were depleted in 8- to 10-week-old male C57BL/6 mice (n=8/group) by intracerebroventricular application of clodronate-loaded liposomes and compared with mice with vehicle liposome injections. Seven days later, SAH was induced by filament perforation under continuous monitoring of CBF and intracranial pressure. Results were compared with sham-operated animals and animals who underwent SAH induction but no liposome injection (n=4/group each). Six hours after SAH induction or sham surgery, numbers of microvasospasms per volume of interest and % of affected pial and penetrating arterioles were examined in 9 standardized regions of interest per animal by in vivo 2-photon microscopy. Depletion of PVMs was proven by quantification of PVMs/mm3 identified by immunohistochemical staining for CD206 and Collagen IV. Statistical significance was tested with t tests for parametric data and Mann-Whitney U test for nonparametric data. RESULTS PVMs were located around pial and intraparenchymal arterioles and were effectively depleted by clodronate from 671±28 to 46±14 PVMs/mm3 (P<0.001). After SAH, microvasospasms was observed in pial arteries and penetrating and precapillary arterioles and were accompanied by an increase to 1405±142 PVMs/mm3. PVM depletion significantly reduced the number of microvasospasms from 9 IQR 5 to 3 IQR 3 (P<0.001). CONCLUSIONS Our results suggest that PVMs contribute to the formation of microvasospasms after experimental SAH.
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Affiliation(s)
- Xiangjiang Lin
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
| | - Igor Khalin
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
| | - Biyan Nathanael Harapan
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Department of Neurosurgery, Munich University Hospital, Germany (B.N.H., N.A.T., J.S.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
| | - Nicole Angela Terpolilli
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Department of Neurosurgery, Munich University Hospital, Germany (B.N.H., N.A.T., J.S.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
| | - Julian Schwarting
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Department of Neurosurgery, Munich University Hospital, Germany (B.N.H., N.A.T., J.S.)
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische University Munich, Germany (J.S.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD) (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
- Munich Cluster for Systems Neurology (SyNergy), Germany (X.L., I.K., B.N.H., N.A.T., J.S., N.P.)
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Abstract
BACKGROUND AND PURPOSE Subarachnoid hemorrhage (SAH) is associated with acute and delayed cerebral ischemia resulting in high acute mortality and severe chronic neurological deficits. Spasms of the pial and intraparenchymal microcirculation (microvasospasms) contribute to acute cerebral ischemia after SAH; however, the underlying mechanisms remain unknown. We hypothesize that free iron (Fe3+) released from hemolytic red blood cells into the subarachnoid space may be involved in microvasospasms formation. METHODS Male C57BL/6 mice (n=8/group) received 200 mg/kg of the iron scavenger deferoxamine or vehicle intravenously and were then subjected to SAH by filament perforation. Microvasospasms of pial and intraparenchymal vessels were imaged three hours after SAH by in vivo 2-photon microscopy. RESULTS Microvasospasms occurred in all investigated vessel categories down to the capillary level. Deferoxamine significantly reduced the number of microvasospasms after experimental SAH. The effect was almost exclusively observed in larger pial arterioles (>30 µm) covered with blood. CONCLUSIONS These results provide proof-of-principle evidence that Fe3+ is involved in the formation of arteriolar microvasospasms after SAH and that arteriolar and capillary microvasospasms are triggered by different mechanisms. Deciphering the mechanisms of Fe3+-induced microvasospasms may result in novel therapeutic strategies for SAH patients.
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Affiliation(s)
- Hanhan Liu
- Institute for Stroke and Dementia Research (H.L., J.S., N.A.T., K.N., N.P.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
| | - Julian Schwarting
- Institute for Stroke and Dementia Research (H.L., J.S., N.A.T., K.N., N.P.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
- Department of Neurosurgery (J.S., N.A.T.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
| | - Nicole Angela Terpolilli
- Institute for Stroke and Dementia Research (H.L., J.S., N.A.T., K.N., N.P.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
- Munich Cluster of Systems Neurology (Synergy), Germany (N.A.T., K.N., N.P.)
| | - Kathrin Nehrkorn
- Institute for Stroke and Dementia Research (H.L., J.S., N.A.T., K.N., N.P.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
- Munich Cluster of Systems Neurology (Synergy), Germany (N.A.T., K.N., N.P.)
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (H.L., J.S., N.A.T., K.N., N.P.), University of Munich Medical Center, Ludwig-Maximilians-University (LMU), Germany
- Munich Cluster of Systems Neurology (Synergy), Germany (N.A.T., K.N., N.P.)
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Wehn AC, Khalin I, Duering M, Hellal F, Culmsee C, Vandenabeele P, Plesnila N, Terpolilli NA. RIPK1 or RIPK3 deletion prevents progressive neuronal cell death and improves memory function after traumatic brain injury. Acta Neuropathol Commun 2021; 9:138. [PMID: 34404478 PMCID: PMC8369637 DOI: 10.1186/s40478-021-01236-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/27/2021] [Indexed: 01/02/2023] Open
Abstract
Traumatic brain injury (TBI) causes acute and subacute tissue damage, but is also associated with chronic inflammation and progressive loss of brain tissue months and years after the initial event. The trigger and the subsequent molecular mechanisms causing chronic brain injury after TBI are not well understood. The aim of the current study was therefore to investigate the hypothesis that necroptosis, a form a programmed cell death mediated by the interaction of Receptor Interacting Protein Kinases (RIPK) 1 and 3, is involved in this process. Neuron-specific RIPK1- or RIPK3-deficient mice and their wild-type littermates were subjected to experimental TBI by controlled cortical impact. Posttraumatic brain damage and functional outcome were assessed longitudinally by repetitive magnetic resonance imaging (MRI) and behavioral tests (beam walk, Barnes maze, and tail suspension), respectively, for up to three months after injury. Thereafter, brains were investigated by immunohistochemistry for the necroptotic marker phosphorylated mixed lineage kinase like protein(pMLKL) and activation of astrocytes and microglia. WT mice showed progressive chronic brain damage in cortex and hippocampus and increased levels of pMLKL after TBI. Chronic brain damage occurred almost exclusively in areas with iron deposits and was significantly reduced in RIPK1- or RIPK3-deficient mice by up to 80%. Neuroprotection was accompanied by a reduction of astrocyte and microglia activation and improved memory function. The data of the current study suggest that progressive chronic brain damage and cognitive decline after TBI depend on the expression of RIPK1/3 in neurons. Hence, inhibition of necroptosis signaling may represent a novel therapeutic target for the prevention of chronic post-traumatic brain damage.
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Schwarting J, Nehrkorn K, Liu H, Plesnila N, Terpolilli NA. Role of Pial Microvasospasms and Leukocyte Plugging for Parenchymal Perfusion after Subarachnoid Hemorrhage Assessed by In Vivo Multi-Photon Microscopy. Int J Mol Sci 2021; 22:8444. [PMID: 34445151 PMCID: PMC8395146 DOI: 10.3390/ijms22168444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 12/05/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is associated with acute and delayed cerebral ischemia. We suggested spasms of pial arterioles as a possible mechanism; however, it remained unclear whether and how pial microvasospasms (MVSs) induce cerebral ischemia. Therefore, we used in vivo deep tissue imaging by two-photon microscopy to investigate MVSs together with the intraparenchymal microcirculation in a clinically relevant murine SAH model. Male C57BL/6 mice received a cranial window. Cerebral vessels and leukocytes were labelled with fluorescent dyes and imaged by in vivo two-photon microscopy before and three hours after SAH induced by filament perforation. After SAH, a large clot formed around the perforation site at the skull base, and blood distributed along the perivascular space of the middle cerebral artery up to the cerebral cortex. Comparing the cerebral microvasculature before and after SAH, we identified three different patterns of constrictions: pearl string, global, and bottleneck. At the same time, the volume of perfused intraparenchymal vessels and blood flow velocity in individual arterioles were significantly reduced by more than 60%. Plugging of capillaries by leukocytes was observed but infrequent. The current study demonstrates that perivascular blood is associated with spasms of pial arterioles and that these spasms result in a significant reduction in cortical perfusion after SAH. Thus, the pial microvasospasm seems to be an important mechanism by which blood in the subarachnoid space triggers cerebral ischemia after SAH. Identifying the mechanisms of pial vasospasm may therefore result in novel therapeutic options for SAH patients.
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Affiliation(s)
- Julian Schwarting
- Institute for Stroke and Dementia Research, Munich University Hospital, Graduate School of Systemic Neurosciences, Munich Cluster for Systems Neurology (SyNergy), Ludwig-Maximilians-University, 81377 Munich, Germany; (J.S.); (K.N.); (H.L.); (N.A.T.)
- Department of Neurosurgery, Munich University Hospital, 81377 Munich, Germany
| | - Kathrin Nehrkorn
- Institute for Stroke and Dementia Research, Munich University Hospital, Graduate School of Systemic Neurosciences, Munich Cluster for Systems Neurology (SyNergy), Ludwig-Maximilians-University, 81377 Munich, Germany; (J.S.); (K.N.); (H.L.); (N.A.T.)
| | - Hanhan Liu
- Institute for Stroke and Dementia Research, Munich University Hospital, Graduate School of Systemic Neurosciences, Munich Cluster for Systems Neurology (SyNergy), Ludwig-Maximilians-University, 81377 Munich, Germany; (J.S.); (K.N.); (H.L.); (N.A.T.)
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research, Munich University Hospital, Graduate School of Systemic Neurosciences, Munich Cluster for Systems Neurology (SyNergy), Ludwig-Maximilians-University, 81377 Munich, Germany; (J.S.); (K.N.); (H.L.); (N.A.T.)
| | - Nicole Angela Terpolilli
- Institute for Stroke and Dementia Research, Munich University Hospital, Graduate School of Systemic Neurosciences, Munich Cluster for Systems Neurology (SyNergy), Ludwig-Maximilians-University, 81377 Munich, Germany; (J.S.); (K.N.); (H.L.); (N.A.T.)
- Department of Neurosurgery, Munich University Hospital, 81377 Munich, Germany
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Terpolilli NA, Ueberschaer M, Niyazi M, Hintschich C, Egensperger R, Muacevic A, Thon N, Tonn JC, Schichor C. Long-term outcome in orbital meningiomas: progression-free survival after targeted resection combined with early or postponed postoperative radiotherapy. J Neurosurg 2019; 133:1-11. [PMID: 31200373 DOI: 10.3171/2019.3.jns181760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 03/12/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In meningiomas involving the orbit and optic canal, surgery is the mainstay of therapy. However, radical resection is often limited to avoid functional damage, so multidisciplinary treatment concepts are implemented. Data on the timing and value of early postoperative radiotherapy (PORT) are scarce. This retrospective study analyzes outcomes in patients who underwent targeted resection alone or in combination with early PORT. METHODS Patients undergoing resection of orbit-associated WHO grade I meningiomas from January 1999 to December 2013 who presented to the authors' department at least twice for follow-up were included. Clinical and radiological findings were analyzed retrospectively. Patients were stratified into two cohorts: follow-up with MRI scans at regular intervals, i.e., the watch and wait (W&W) group, and a PORT group receiving PORT within 6 months after surgery in addition to MRI follow-up. Patients in the W&W group were scheduled for treatment when tumor progression was detected by imaging. RESULTS One hundred twenty-two patients were included. The mean follow-up was 70 months. The most common symptoms at presentation were visual disturbances; 87.7% of patients received Simpson grade II-III targeted partial resection. Twenty-three patients received PORT, and 99 patients were regularly observed with MRI scans (W&W group). Tumor recurrence/progression occurred significantly later (76.3 vs 40.7 months) and less frequently in the PORT group (13%) than in the W&W group (46.5%). Cases of recurrence were diagnosed an average of 39 months after initial surgery in both groups. PORT patients demonstrated significantly less visual impairment at last follow-up. CONCLUSIONS These results indicate that receiving PORT early after targeted partial resection might help to postpone tumor recurrence and the need for additional treatment, while preserving or even improving visual outcome.
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Affiliation(s)
- Nicole Angela Terpolilli
- Departments of1Neurosurgery
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Moritz Ueberschaer
- Departments of1Neurosurgery
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maximilian Niyazi
- 2Radiation Oncology
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christoph Hintschich
- 3Ophthalmology, and
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rupert Egensperger
- 4Neuropathology, University Hospital, LMU Munich
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Niklas Thon
- Departments of1Neurosurgery
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jörg-Christian Tonn
- Departments of1Neurosurgery
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christian Schichor
- Departments of1Neurosurgery
- 6German Cancer Consortium (DKTK), partner site Munich, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Affiliation(s)
- Nicole Angela Terpolilli
- From the Department of Neurosurgery (N.A.T.), Department of Neuroradiology (C.B.), Institute for Stroke and Dementia Research (D.B., N.P.), and Munich Cluster for Systems Neurology (SyNergy) (N.P.), University of Munich Medical Center, Munich, Germany
| | - Christian Brem
- From the Department of Neurosurgery (N.A.T.), Department of Neuroradiology (C.B.), Institute for Stroke and Dementia Research (D.B., N.P.), and Munich Cluster for Systems Neurology (SyNergy) (N.P.), University of Munich Medical Center, Munich, Germany
| | - Dominik Bühler
- From the Department of Neurosurgery (N.A.T.), Department of Neuroradiology (C.B.), Institute for Stroke and Dementia Research (D.B., N.P.), and Munich Cluster for Systems Neurology (SyNergy) (N.P.), University of Munich Medical Center, Munich, Germany
| | - Nikolaus Plesnila
- From the Department of Neurosurgery (N.A.T.), Department of Neuroradiology (C.B.), Institute for Stroke and Dementia Research (D.B., N.P.), and Munich Cluster for Systems Neurology (SyNergy) (N.P.), University of Munich Medical Center, Munich, Germany
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Pfeifenbring S, von Baumgarten L, Schüller U, Rosewich H, Thal DR, Wirtz CR, Hecht M, Terpolilli NA, Brück W. Biopsy findings of symptomatic cerebral X-linked adrenoleucodystrophy and histological differentiation from multiple sclerosis. Neuropathol Appl Neurobiol 2015; 40:658-61. [PMID: 24117509 DOI: 10.1111/nan.12089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/03/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Sabine Pfeifenbring
- Department of Neuropathology, University Medical Centre, Georg August University, Göttingen, Germany
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