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Neumann A, Weber W, Küchler J, Schacht H, Jensen-Kondering U, Berlis A, Schramm P. Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018-2021: an overview of the current care situation. ROFO-FORTSCHR RONTG 2023; 195:1018-1026. [PMID: 37467777 DOI: 10.1055/a-2102-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Evaluation of endovascular therapies for cerebral vasospasm (CVS) documented in the DeGIR registry from 2018-2021 to analyse the current clinical care situation in Germany. METHODS Retrospective analysis of the clinical and procedural data on endovascular spasm therapies (EST) documented anonymously in the DeGIR registry. We analysed: pre-interventional findings of CTP and consciousness; radiation dose applied, interventional-technical parameters (local medication, devices, angiographic result), post-interventional symptoms, complications and mortality. RESULTS 3584 patients received a total of 7628 EST (median age/patient: 53 [range: 13-100, IQR: 44-60], 68.2 % women) in 91 (2018), 92 (2019), 100 (2020) and 98 (2021) centres; 5388 (70.6 %) anterior circulation and 378 (5 %) posterior circulation (both involved in 1862 cases [24.4 %]). EST was performed once in 2125 cases (27.9 %), with a mean of 2.1 EST/patient. In 7476 times, purely medicated EST were carried out (nimodipine: 6835, papaverine: 401, nitroglycerin: 62, other drug not specified: 239; combinations: 90). Microcatheter infusions were documented in 1132 times (14.8 %). Balloon angioplasty (BA) (additional) was performed in 756 EST (9.9 %), other mechanical recanalisations in 154 cases (2 %) and stenting in 176 of the EST (2.3 %). The median dose area product during ET was 4069 cGycm² (drug: 4002/[+]BA: 8003 [p < 0.001]). At least 1 complication occurred in 95 of all procedures (1.2 %) (drug: 1.1 %/[+]BA: 4.2 % [p < 0.001]). Mortality associated with EST was 0.2 % (n = 18). After EST, overall improvement or elimination of CVS was found in 94.2 % of cases (drug: 93.8 %/[+]BA: 98.1 % [p < 0.001]). In a comparison of the locally applied drugs, papaverine eliminated CVS more frequently than nimodipine (p = 0.001). CONCLUSION EST have a moderate radiation exposure and can be performed with few complications. Purely medicated EST are predominantly performed, especially with nimodipine. With (additional) BA, radiation exposure, complication rates and angiographic results are higher or better. When considering drug EST alone, there is evidence for an advantage of papaverine over nimodipine, but a different group size has to be taken into account. In the analysis of EST, the DeGIR registry data are suitable for answering more specific questions, especially due to the large number of cases; for this purpose, further subgroupings should be sought in the data documentation. KEY POINTS · In Germany, there are currently no guidelines for the endovascular treatment of cerebral vasospasm following spontaneous subarachnoid hemorrhage.. · In addition to oral nimodipine administration endovascular therapy is used to treat cerebral vasospasm in most hospitals.. · This is the first systematic evaluation of nationwide registry data on endovascular treatment of cerebral vasopasm in Germany.. · This real-world data shows that endovascular treatment for cerebral vasospasm has a moderate radiation exposure and can be performed with few complications overall. With (additional) balloon angioplasty, radiation exposure, complication rates and angiographic therapy results are higher or better.. CITATION FORMAT · Neumann A, Weber W, Küchler J et al. Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018-2021: an overview of the current care situation. Fortschr Röntgenstr 2023; 195: 1018 - 1026.
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Affiliation(s)
- Alexander Neumann
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Werner Weber
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Ulf Jensen-Kondering
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Germany
| | - Peter Schramm
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
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Samuelsson J, Sunila M, Rentzos A, Nilsson D. Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid haemorrhage - neurological and radiological outcome. Neuroradiol J 2021; 35:213-219. [PMID: 34350797 PMCID: PMC8958555 DOI: 10.1177/19714009211036695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objectives Cerebral vasospasm is a known complication to aneurysmal subarachnoid
haemorrhage, which can lead to severe morbidity. Intra-arterial vasodilation
therapy is widely used as a last resort treatment in patients with
symptomatic refractory cerebral vasospasm but there is limited data about
the outcome. The purpose of this study is to evaluate the neurological and
radiological outcome in patients treated with intra-arterial nimodipine in
relation to cerebral infarction, procedure-related complications and
clinical outcome. Methods Patients with refractory cerebral vasospasm treated with intra-arterial
nimodipine during 2009–2020 at Sahlgrenska University Hospital were
retrospectively reviewed. Neurological outcome (modified Rankin Scale) at 30
days and 6 months, development of cerebral infarction after intra-arterial
nimodipine treatment and procedure-related complications were studied. Results Forty-eight patients were treated with intra-arterial nimodipine. A good
outcome (modified Rankin Scale 0–2) was seen in 25%
(n = 12) of the patients after 30 days and in 47%
(n = 22) of the patients after six months. Infarction
related to the vasospastic vessel after treatment with intra-arterial
nimodipine was seen in 60% (n = 29) of the patients. A
total of 124 procedures with intra-arterial nimodipine were performed where
complications were seen in 10 (21%) patients in 10 (8%) procedures. Four
(8%) patients died within 30 days. Conclusions A majority of patients developed an ischaemic cerebral infarction in spite of
intra-arterial nimodipine treatment. However, a good clinical recovery was
seen in almost half of the patients after 6 months. Minor complications
occurred in one out of five patients.
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Affiliation(s)
- Jennifer Samuelsson
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Sweden
| | - Merete Sunila
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden
| | - Alexandros Rentzos
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Sweden.,Department of Radiology, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Nilsson
- Institute of Neurosciences and Physiology, Gothenburg University, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Sweden
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Neumann A, Küchler J, Ditz C, Krajewski K, Leppert J, Schramm P, Schacht H. Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments. Stroke Vasc Neurol 2021; 6:16-24. [PMID: 32709603 PMCID: PMC8005899 DOI: 10.1136/svn-2020-000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/06/2020] [Accepted: 06/24/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND For endovascular rescue therapy (ERT) of cerebral vasospasm (CVS) due to spontaneous subarachnoid haemorrhage (sSAH), non-compliant (NCB) and compliant (CB) balloons are used with both balloon types bearing the risk of vessel injury due to specific mechanical properties. Although severe delayed arterial narrowing after transluminal balloon angioplasty (TBA) for CVS has sporadically been described, valid data concerning incidence and relevance are missing. Our aim was to analyse the radiological follow-up (RFU) of differently TBA-treated arteries (CB or NCB). METHODS Twelve patients with utilisation of either NCB or CB for CVS were retrospectively analysed for clinical characteristics, ERT, functional outcome after 3 months and RFU. Compared with the initial angiogram, we classified delayed arterial narrowing as mild, moderate and severe (<30%, 30%-60%, respectively >60% calibre reduction). RESULTS Twenty-three arteries were treated with CB, seven with NCB. The median first RFU was 11 months after TBA with CB and 10 after NCB. RFU was performed with catheter angiography in 18 arteries (78%) treated with CB and in five (71%) after NCB; magnetic resonance angiography was acquired in five vessels (22%) treated with CB and in two (29%) after NCB. Mild arterial narrowing was detected in three arteries (13%) after CB and in one (14%) after NCB. Moderate or severe findings were neither detected after use of CB nor NCB. CONCLUSION We found no relevant delayed arterial narrowing after TBA for CVS after sSAH. Despite previous assumptions that CB provides for more dilatation in segments adjacent to CVS, we observed no disadvantages concerning long-term adverse effects. Our data support TBA as a low-risk treatment option.
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Affiliation(s)
- Alexander Neumann
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Küchler
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Claudia Ditz
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Kara Krajewski
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Jan Leppert
- Neurosurgery, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Peter Schramm
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
| | - Hannes Schacht
- Neuroradiology, University Medical Center Schleswig Holstein Lubeck Campus, Lubeck, Germany
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Deuschl C, Darkwah Oppong M, Styczen H, Markhardt L, Wrede K, Jabbarli R, Sure U, Radbruch A, Forsting M, Wanke I, Mönninghoff C. Therapy results of pericallosal aneurysms: A retrospective unicenter study. Clin Pract 2020; 10:1257. [PMID: 33014320 PMCID: PMC7512184 DOI: 10.4081/cp.2020.1257] [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: 04/20/2020] [Accepted: 07/30/2020] [Indexed: 12/27/2022] Open
Abstract
This retrospective study aims to compare treatment results of ruptured and unruptured pericallosal artery aneurysms (PAAs) regarding patient outcome and aneurysm recurrence after endovascular treatment (EVT) and neurosurgical treatment (NT). A total of 67 patients with PAA were admitted to our hospital, 44 patients with subarachnoidal hemorrhage (SAH) due to a ruptured PAA and 23 patients with unruptured PAA. The radiographic features of PAA were collected from pre-treatment digital subtraction angiography. In addition, demographic, clinical and radiographic parameters of all patients were recorded. Outcome was measured based on the modified Rankin scale (mRS) at 6 months after admission (favorable mRS score, 0-2 vs unfavorable mRS score, 3-6). Overall 46 patients underwent EVT and 21 patients NT. Six months after discharge 24 patients with SAH had a favorable outcome (mRS 0-2) and 16 patients an unfavorable outcome (mRS 3-6). Mortality rate of patients with SAH was 9.1% (4/44). Overall aneurysm recurrence was treated in 13 % of patients in the EVT cohort (6/46), whereas patients treated with NT had no recurrence. All patients with unruptured PAA had a favorable outcome. EVT and NT of PAA show comparable good results, although aneurysm recurrence occurs more often after EVT.
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Affiliation(s)
- Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | | | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Lisa Markhardt
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Karsten Wrede
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ramazan Jabbarli
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Ulrich Sure
- Clinic for Neurosurgery, University Hospital Essen, Essen, Germany
| | - Alexander Radbruch
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Isabel Wanke
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.,Center for Neuroradiology, Clinic Hirslanden, Zurich, Switzerland
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany.,Clinic for Neuroradiology, Clemenshospital Muenster, Germany
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Transluminal balloon angioplasty for cerebral vasospasm after spontaneous subarachnoid hemorrhage: A single-center experience. Clin Neurol Neurosurg 2019; 188:105590. [PMID: 31759310 DOI: 10.1016/j.clineuro.2019.105590] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/28/2019] [Accepted: 11/05/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES After spontaneous subarachnoid hemorrhage (sSAH), cerebral vasospasm (CVS) is a common complication, potentially resulting in infarction mainly responsible for a poor outcome. Intra-arterial vasodilators lead to transient increase of brain perfusion, but only transluminal balloon angioplasty (TBA) promises longer-lasting effects, though it poses the risk of severe complications. Until now, the precise impact of TBA on the course of CVS is not yet finally clarified. Thus we aimed to identify risk factors of recurrent CVS and vasospasm-related infarction following TBA. PATIENTS AND METHODS We analyzed 35 patients with CVS after sSAH who received TBA (41 procedures, 99 vessel segments). Gender, age, WFNS grade and Fisher scale, occurrence of intraventricular and intracerebral hemorrhage, localization of the aneurysm and the initial treatment modality were obtained. We assessed functional outcome after 3 months and in-hospital mortality. TBA was analyzed concerning time point, localization, technique, complications and angiographic response. Furthermore, recurrence of CVS and vasospasm-related infarction after TBA were described and risk factors were identified with logistic regression analyses. RESULTS In 7 of 35 patients (20%) and in 16 of 99 vessel segments (16%) previously treated with TBA, we found recurrent CVS. Vasospasm-related infarction occurred in 18 cases (18%) in the arterial territories of the TBA-treated vessel segments. The angiographic effect after TBA was mostly classified as good (87%), good response was negatively associated with recurrent CVS (p = 0.004) and vasospasm-related infarction (p = 0.001). We identified only the male gender as a risk factor for vasospasm-related infarction after TBA (p = 0.040). In connection with TBA, only one complication occurred (intracranial dissection). CONCLUSION Our data support TBA as a safe and effective therapy for CVS. Nevertheless, recurrent CVS and vasospasm-related infarction were common after TBA and not predictable by clinical conditions on admission or the localization of CVS. A moderate or poor angiographic response after TBA was identified as a risk factor for both, recurrent CVS and vasospasm-related infarction, while male gender was associated with a higher risk of vasospasm-related infarction. Our results augment the still sparse evidence concerning optimal patient selection for this method and provide new aspects for individual therapy decisions.
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Li K, Barras CD, Chandra RV, Kok HK, Maingard JT, Carter NS, Russell JH, Lai L, Brooks M, Asadi H. A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 126:513-527. [PMID: 30898740 DOI: 10.1016/j.wneu.2019.03.083] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage. OBJECTIVE To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era. METHODS A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage. RESULTS Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy. CONCLUSIONS Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.
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Affiliation(s)
- Kenny Li
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia.
| | - Christen D Barras
- University of Adelaide, North Terrace Campus, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ronil V Chandra
- Interventional Neuroradiology Service, Monash Health, Clayton, Victoria, Australia
| | - Hong K Kok
- Interventional Radiology Service, Northern Health, Epping, Victoria, Australia
| | - Julian T Maingard
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Nicole S Carter
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Leon Lai
- Department of Neurosurgery, Monash Health, Clayton, Victoria, Australia
| | - Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Hamed Asadi
- School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia; Interventional Radiology Service, Department of Radiology, Austin Hospital, Heidelberg, Victoria, Australia; Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
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Weiss M, Conzen C, Mueller M, Wiesmann M, Clusmann H, Albanna W, Schubert GA. Endovascular Rescue Treatment for Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Is Safe and Effective. Front Neurol 2019; 10:136. [PMID: 30858818 PMCID: PMC6398410 DOI: 10.3389/fneur.2019.00136] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
Abstract
Background: The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear. Objective: The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA). Methods: In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (ptiO2, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment. Results: We included 33 consecutive patients with 54 ERT (IAN n = 35; TBA n = 13; TBA + IAN n = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; ptiO2 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, p < 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, p <0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, p < 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment (n = 16, 48.5%) was independently associated with preinterventional ptiO2 < 5 mmHg (p <0.01) and early (<72 h) discontinuation of IAN treatment (p = 0.08). DCI related cerebral infarction was noted in n = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for n = 11 (35.5%) patients. Conclusion: Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.
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Affiliation(s)
- Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Marguerite Mueller
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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