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Amin SJ, Aghajan Y, Webb AJ. Clinical experience with bromocriptine for central hyperthermia after brain insult. Brain Inj 2024:1-7. [PMID: 38555516 DOI: 10.1080/02699052.2024.2337231] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Bromocriptine is a dopamine receptor agonist used for central hyperthermia with limited data. We describe our single-center experience utilizing bromocriptine for central hyperthermia, including the population treated, most common dosing regimens, adverse events, and discontinuation reasons. METHODS A retrospective study was conducted screening patients who were admitted to intensive care units for acute neurological insults and administered bromocriptine for central hyperthermia between April 2016 and September 2022. Baseline characteristics, disease severity markers, and bromocriptine doses were collected. Body temperatures prior to the first dose of bromocriptine, at the time of dose, and after each dose were recorded. Co-administration of additional hyperthermia management therapies was noted. RESULTS Thirty patients were included. The most common diagnosis was traumatic brain injury (TBI) (N = 14). The most common reason for discontinuation was resolution of indication (N = 14). Discontinuation due to mild adverse effects occurred in four patients; hepatotoxicity was the most common. There was a paired mean difference of -0.37°C (p = 0.005) between temperatures before and after bromocriptine initiation. CONCLUSION Bromocriptine is a potential therapy for the management of central hyperthermia in patients with severe acute neurologic insults who have failed other therapies. Bromocriptine was well tolerated and associated with a low incidence of adverse events.
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Affiliation(s)
- Suneri J Amin
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, USA
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yasmin Aghajan
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, Boston, USA
| | - Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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2
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Aghajan Y. Smoke Angiogram. Neurology 2023; 101:909. [PMID: 37596041 DOI: 10.1212/wnl.0000000000207767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/26/2023] [Indexed: 08/20/2023] Open
Affiliation(s)
- Yasmin Aghajan
- From the Department of Neurology, Brigham and Women's Hospital, Boston, MA.
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3
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Aghajan Y, Daboul L, Molyneaux BJ. Bilateral medial medullary infarct causing stepwise tetraparesis: delayed appearance of the 'heart-shaped' sign. Pract Neurol 2023; 23:430-431. [PMID: 37147121 DOI: 10.1136/pn-2023-003732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Yasmin Aghajan
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lynn Daboul
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bradley J Molyneaux
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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4
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Aghajan Y. Right Brain: Breathe. Neurology 2023; 101:544-545. [PMID: 37407258 PMCID: PMC10516276 DOI: 10.1212/wnl.0000000000207548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/08/2023] [Indexed: 07/07/2023] Open
Affiliation(s)
- Yasmin Aghajan
- From the Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston.
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Affiliation(s)
- Yasmin Aghajan
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Bilodeau PA, Aghajan Y, Izzy S. Rash, Facial Droop, and Multifocal Intracranial Stenosis Due to Varicella Zoster Virus Vasculitis. Neurohospitalist 2023; 13:178-182. [PMID: 37064929 PMCID: PMC10091438 DOI: 10.1177/19418744221150301] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Background: This is a case of multifocal intracranial stenosis in a 74 year old male ultimately discovered to be due to Varicella Zoster Virus infection. Purpose: We highlight the importance of a broad differential diagnosis, even when the most likely etiology of intracranial stenosis is atherosclerosis. Our paper reviews the differential diagnosis as well as "red flags" for intracranial vasculopathy. Even though intracranial atherosclerotic disease is the most common cause of vasculopathy, infectious or inflammatory vasculitis should be considered on the differential. Conclusions: Before considering bypass surgery or other invasive neurosurgical procedures, ensure reversible causes of vasculopathy have been ruled out. The presence of cranial neuropathies, rash, and/or elevated inflammatory markers should be red flags for vasculitis in patients presenting with stroke.
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Affiliation(s)
| | | | - Saef Izzy
- Brigham and Women's
Hospital, Boston, MA, USA
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Gritsch S, Aghajan Y, Kozanno L, Chiu D, Jordan JT, Frosch MP, Shankar G, Kimberly WT. Teaching NeuroImage: Subacute Quadriparesis From Intramedullary Spinal Cord Infiltrating Glioma With TERT Promoter Mutation. Neurology 2023:WNL.0000000000207148. [PMID: 36805433 DOI: 10.1212/wnl.0000000000207148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Affiliation(s)
- Simon Gritsch
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Yasmin Aghajan
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Liana Kozanno
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Daniel Chiu
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Justin T Jordan
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Matthew P Frosch
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Ganesh Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
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8
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Kadar A, Shah VS, Mendoza DP, Lai PS, Aghajan Y, Piazza G, Camargo EC, Viswanathan K. Case 39-2021: A 26-Year-Old Woman with Respiratory Failure and Altered Mental Status. N Engl J Med 2021; 385:2464-2474. [PMID: 34936743 DOI: 10.1056/nejmcpc2107355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Aran Kadar
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Viral S Shah
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Dexter P Mendoza
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Peggy S Lai
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Yasmin Aghajan
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Gregory Piazza
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Erica C Camargo
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
| | - Kartik Viswanathan
- From the Department of Pulmonary and Critical Care Medicine, Newton-Wellesley Hospital, Newton (A.K.), and the Department of Pulmonary and Critical Care Medicine, Tufts Medical School (A.K.), the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Massachusetts General Hospital, the Departments of Pulmonary and Critical Care Medicine (V.S.S.), Radiology (D.P.M.), Medicine (P.S.L., G.P.), Neurology (Y.A., E.C.C.), and Pathology (K.V.), Harvard Medical School, and the Department of Medicine, Brigham and Women's Hospital (G.P.), Boston - all in Massachusetts
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Aghajan Y, Mitchell RN, Bhattacharyya S, Hsu TYT, Klein JP. Teaching NeuroImage: Bilateral Middle Cerebellar Peduncle Stroke in Giant Cell Arteritis. Neurology 2021; 98:e105-e106. [PMID: 34667081 DOI: 10.1212/wnl.0000000000012953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Yasmin Aghajan
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
| | | | | | - Tiffany Y-T Hsu
- Department of Rheumatology, Brigham and Women's Hospital, Boston, MA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Boston, MA
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10
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Aghajan Y, Yu A, Jacobson CA, Kim AI, Kean L, Robertson M, Vaitkevicius H. Myelopathy Due to CAR-T Related Neurotoxicity Treated with Siltuximab. Neurol Clin Pract 2021; 11:e944-e946. [DOI: 10.1212/cpj.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/18/2020] [Indexed: 11/15/2022]
Abstract
Chimeric antigen receptor T (CART) cell therapy is highly effective for relapsed/refractory hematologic malignancy [1,2]; however, cytokine release syndrome (CRS) and neurotoxicity are observed in up to 77% of patients [3]. In large case series, the most common presentations of neurotoxicity were encephalopathy (57%), headache (42%), tremor (38%) and aphasia (35%). CART mediated spinal cord toxicity is not well characterized. Structural neurologic damage (stroke and intracranial hemorrhage) was only observed in 1-2% and seizures were seen in 1%-8% of cases [3, 4]. Neuroimaging findings in patients with neurotoxicity are rare and not specific.
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11
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Aghajan Y, Malicki DM, Levy ML, Crawford JR. Atypical anaplastic astrocytoma with unique molecular features and diffuse leptomeningeal spread in a child with long-term survival. BMJ Case Rep 2019; 12:12/2/e228153. [PMID: 30765449 DOI: 10.1136/bcr-2018-228153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Paediatric high-grade gliomas, including glioblastoma and anaplastic astrocytoma, make up 8%-12% of paediatric central nervous system tumours 1 and have poor prognosis, with 2-year survival less than 30% 2 and overall survival less than 10%. The only known prognostic factors in this population include extent of resection and tumour histological grade. We present the case of a 9-year-old boy with disseminated anaplastic astrocytoma treated with subtotal resection, craniospinal radiation and temozolomide, with 8-year survival despite metastatic disease at presentation and subtotal resection. Next generation cancer gene panel sequencing revealed an usual pattern of 12 amplifications and four mutations not previously described.
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Affiliation(s)
- Yasmin Aghajan
- School of Medicine, UC San Diego, La Jolla, California, USA
| | - Denise M Malicki
- Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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12
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Aghajan Y, Malicki DM, Levy ML, Crawford JR. Atypical central neurocytoma with novel EWSR1-ATF1 fusion and MUTYH mutation detected by next-generation sequencing. BMJ Case Rep 2019; 12:12/1/bcr-2018-226455. [PMID: 30642852 DOI: 10.1136/bcr-2018-226455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present the case of a 13-year-old boy with a very unusual periventricular atypical central neurocytoma with unique molecular features treated with subtotal surgical resection and photon intensity-modulated radiotherapy. Histological features were most consistent with atypical central neurocytoma. However, next-generation sequencing analysis revealed a novel EWSR1-ATF1 gene fusion (EWSR1-ATF1) as well as a MUTYH mutation. The EWSR1-ATF1 raised the possibility of Ewing sarcoma or angiomatoid fibrous histiocytoma, however, FLI-1 immunohistochemistry was negative. MUTYH mutations have been reported in diffuse midline paediatric glioma. The role of EWSR1-ATF1 and MUTYH mutations in central nervous system tumours is not well established. We present the first case of EWSR1-ATF1 and MUTYH mutation in a rare paediatric atypical central neurocytoma. Further studies are indicated to elucidate the consequences of these gene alterations in the context of paediatric central nervous system tumours as well as to investigate the potential role for targeted therapies.
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Affiliation(s)
- Yasmin Aghajan
- School of Medicine, UC San Diego, La Jolla, California, USA
| | - Denise M Malicki
- Department of Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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13
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Affiliation(s)
- Yasmin Aghajan
- Department of Internal Medicine, UC San Diego, La Jolla, California, USA
| | - Joseph Diaz
- Department of Internal Medicine, UC San Diego, La Jolla, California, USA
| | - Emily Sladek
- Department of Internal Medicine, UC San Diego, La Jolla, California, USA
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16
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Aghajan Y, Yoon JM, Crawford JR. Severe vincristine-induced polyneuropathy in a teenager with anaplastic medulloblastoma and undiagnosed Charcot-Marie-Tooth disease. BMJ Case Rep 2017; 2017:bcr-2016-218981. [PMID: 28438772 DOI: 10.1136/bcr-2016-218981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Severe neuropathy is a known adverse effect of vincristine in patients with Charcot-Marie-Tooth disease (CMT). We present the case of a 16-year-old girl with anaplastic medulloblastoma treated with gross total resection and high-dose craniospinal radiation with adjuvant vincristine chemotherapy who developed acute-onset severe quadriplegia and vocal cord paralysis. Vincristine and radiation therapy were discontinued. Although her neuropathy slowly improved over several weeks, she developed metastatic extraneural medulloblastoma and died 5 months after diagnosis. Subsequent genetic testing revealed previously asymptomatic and undiagnosed CMT1A. Our case highlights the importance of early recognition of acute vincristine neurotoxicity that should raise suspicion of an underlying hereditary neuropathy.
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Affiliation(s)
- Yasmin Aghajan
- School of Medicine, University of California San Diego, San Diego, California, USA
| | - Janet M Yoon
- Division of Hematology-Oncology, Department of Pediatrics, Rady Children's Hospital-San Diego, San Diego, California, USA
| | - John Ross Crawford
- Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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Aghajan Y, Levy ML, Newbury RO, Crawford JR. Disseminated pilomyxoid astrocytoma in infancy with novel MUTYH mutation. BMJ Case Rep 2016; 2016:bcr-2016-217764. [PMID: 27797849 DOI: 10.1136/bcr-2016-217764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Robert O Newbury
- Department of Pathology, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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Aghajan Y, Levy ML, Mo JQ, Crawford JR. Acute brainstem haemorrhage as a presenting feature of high-grade glioma. BMJ Case Rep 2016; 2016:bcr-2016-217370. [PMID: 27659914 DOI: 10.1136/bcr-2016-217370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yasmin Aghajan
- University of California San Diego, School of Medicine, San Diego, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Jun Qin Mo
- Department of Pathology, University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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Affiliation(s)
- Yasmin Aghajan
- University of California, San Diego, School of Medicine, La Jolla, California, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Denise M Malicki
- Department of Pathology, Rady Children's Hospital University of California San Diego, San Diego, California, USA
| | - John Ross Crawford
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California, USA
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