1
|
Laudanski K, Elmadhoun O, Mathew A, Kahn-Pascual Y, Kerfeld MJ, Chen J, Sisniega DC, Gomez F. Anesthetic Considerations for Patients with Hereditary Neuropathy with Liability to Pressure Palsies: A Narrative Review. Healthcare (Basel) 2024; 12:858. [PMID: 38667620 PMCID: PMC11050561 DOI: 10.3390/healthcare12080858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominant demyelinating neuropathy characterized by an increased susceptibility to peripheral nerve injury from trauma, compression, or shear forces. Patients with this condition are unique, necessitating distinct considerations for anesthesia and surgical teams. This review describes the etiology, prevalence, clinical presentation, and management of HNPP and presents contemporary evidence and recommendations for optimal care for HNPP patients in the perioperative period. While the incidence of HNPP is reported at 7-16:100,000, this figure may be an underestimation due to underdiagnosis, further complicating medicolegal issues. With the subtle nature of symptoms associated with HNPP, patients with this condition may remain unrecognized during the perioperative period, posing significant risks. Several aspects of caring for this population, including anesthetic choices, intraoperative positioning, and monitoring strategy, may deviate from standard practices. As such, a tailored approach to caring for this unique population, coupled with meticulous preoperative planning, is crucial and requires a multidisciplinary approach.
Collapse
Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55902, USA; (K.L.); (O.E.); (M.J.K.); (J.C.)
| | - Omar Elmadhoun
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55902, USA; (K.L.); (O.E.); (M.J.K.); (J.C.)
| | - Amal Mathew
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA 19104, USA;
| | - Yul Kahn-Pascual
- St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK;
| | - Mitchell J. Kerfeld
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55902, USA; (K.L.); (O.E.); (M.J.K.); (J.C.)
| | - James Chen
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55902, USA; (K.L.); (O.E.); (M.J.K.); (J.C.)
| | - Daniella C. Sisniega
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO 65211, USA
| |
Collapse
|
2
|
Diaz MM, Caylor J, Strigo I, Lerman I, Henry B, Lopez E, Wallace MS, Ellis RJ, Simmons AN, Keltner JR. Toward Composite Pain Biomarkers of Neuropathic Pain—Focus on Peripheral Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:869215. [PMID: 35634449 PMCID: PMC9130475 DOI: 10.3389/fpain.2022.869215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/21/2022] [Indexed: 01/09/2023] Open
Abstract
Chronic pain affects ~10–20% of the U.S. population with an estimated annual cost of $600 billion, the most significant economic cost of any disease to-date. Neuropathic pain is a type of chronic pain that is particularly difficult to manage and leads to significant disability and poor quality of life. Pain biomarkers offer the possibility to develop objective pain-related indicators that may help diagnose, treat, and improve the understanding of neuropathic pain pathophysiology. We review neuropathic pain mechanisms related to opiates, inflammation, and endocannabinoids with the objective of identifying composite biomarkers of neuropathic pain. In the literature, pain biomarkers typically are divided into physiological non-imaging pain biomarkers and brain imaging pain biomarkers. We review both types of biomarker types with the goal of identifying composite pain biomarkers that may improve recognition and treatment of neuropathic pain.
Collapse
Affiliation(s)
- Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
- *Correspondence: Monica M. Diaz
| | - Jacob Caylor
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Irina Strigo
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Imanuel Lerman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Brook Henry
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Eduardo Lopez
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Mark S. Wallace
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Ronald J. Ellis
- Department of Neurosciences, University of California, San Diego, San Diego, CA, United States
| | - Alan N. Simmons
- Department of Psychiatry, San Diego & Center of Excellence in Stress and Mental Health, Veteran Affairs Health Care System, University of California, San Diego, San Diego, CA, United States
| | - John R. Keltner
- Department of Psychiatry, San Diego & San Diego VA Medical Center, University of California, San Diego, San Diego, CA, United States
| |
Collapse
|
3
|
Keltner JR, Tong A, Visser E, Jenkinson M, Connolly CG, Dasca A, Sheringov A, Calvo Z, Umbao E, Mande R, Bilder MB, Sahota G, Franklin DR, Corkran S, Grant I, Archibald S, Vaida F, Brown GG, Atkinson JH, Simmons AN, Ellis RJ. Evidence for a novel subcortical mechanism for posterior cingulate cortex atrophy in HIV peripheral neuropathy. J Neurovirol 2020; 26:530-543. [PMID: 32524422 DOI: 10.1007/s13365-020-00850-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/10/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
We previously reported that neuropathic pain was associated with smaller posterior cingulate cortical (PCC) volumes, suggesting that a smaller/dysfunctional PCC may contribute to development of pain via impaired mind wandering. A gap in our previous report was lack of evidence for a mechanism for the genesis of PCC atrophy in HIV peripheral neuropathy. Here we investigate if volumetric differences in the subcortex for those with neuropathic paresthesia may contribute to smaller PCC volumes, potentially through deafferentation of ascending white matter tracts resulting from peripheral nerve damage in HIV neuropathy. Since neuropathic pain and paresthesia are highly correlated, statistical decomposition was used to separate pain and paresthesia symptoms to determine which regions of brain atrophy are associated with both pain and paresthesia and which are associated separately with pain or paresthesia. HIV+ individuals (N = 233) with and without paresthesia in a multisite study underwent structural brain magnetic resonance imaging. Voxel-based morphometry and a segmentation/registration tool were used to investigate regional brain volume changes associated with paresthesia. Analysis of decomposed variables found that smaller midbrain and thalamus volumes were associated with paresthesia rather than pain. However, atrophy in the PCC was related to both pain and paresthesia. Peak thalamic atrophy (p = 0.004; MNI x = - 14, y = - 24, z = - 2) for more severe paresthesia was in a region with reciprocal connections with the PCC. This provides initial evidence that smaller PCC volumes in HIV peripheral neuropathy are related to ascending white matter deafferentation caused by small fiber damage observed in HIV peripheral neuropathy.
Collapse
Affiliation(s)
- John R Keltner
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA. .,VA San Diego Healthcare System, San Diego, CA, USA. .,UCSD Department of Psychiatry, UCSD HIV Neurobehavioral Research Program, 220 Dickinson Street, Suite B, Mailcode 8231, San Diego, CA, 92103-8231, USA.
| | - Alan Tong
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Eelke Visser
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Mark Jenkinson
- Wellcome Centre for Integrative Neuroimaging, FMRIB, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Colm G Connolly
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - Alyssa Dasca
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Aleks Sheringov
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Zachary Calvo
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Earl Umbao
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Rohit Mande
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Mary Beth Bilder
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Gagandeep Sahota
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Donald R Franklin
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Stephanie Corkran
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Igor Grant
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Sarah Archibald
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - Florin Vaida
- Department of Family and Preventative Medicine, University of California San Diego, San Diego, CA, USA
| | - Gregory G Brown
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
| | - J Hampton Atkinson
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Alan N Simmons
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Ronald J Ellis
- Departments of Neurosciences and Psychiatry, University of California San Diego, San Diego, CA, USA
| | | |
Collapse
|
4
|
Zahr NM, Pohl KM, Pfefferbaum A, Sullivan EV. Central Nervous System Correlates of "Objective" Neuropathy in Alcohol Use Disorder. Alcohol Clin Exp Res 2019; 43:2144-2152. [PMID: 31386216 PMCID: PMC6779503 DOI: 10.1111/acer.14162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/24/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Among the neurological consequences of alcoholism is peripheral neuropathy. Relative to human immunodeficiency virus (HIV) or diabetes-related neuropathies, neuropathy associated with alcohol use disorders (AUD) is understudied. In both the diabetes and HIV literature, emerging evidence supports a central nervous system (CNS) component to peripheral neuropathy. METHODS In seeking a central substrate for AUD-related neuropathy, the current study was conducted in 154 individuals with AUD (43 women, age 21 to 74 years) and 99 healthy controls (41 women, age 21 to 77 years) and explored subjective symptoms (self-report) and objective signs (perception of vibration, deep tendon ankle reflex, position sense, 2-point discrimination) of neuropathy separately. In addition to regional brain volumes, risk factors for AUD-related neuropathy, including age, sex, total lifetime ethanol consumed, nutritional indices (i.e., thiamine, folate), and measures of liver integrity (i.e., γ-glutamyltransferase), were evaluated. RESULTS The AUD group described more subjective symptoms of neuropathy and was more frequently impaired on bilateral perception of vibration. From 5 correlates, the number of AUD-related seizures was most significantly associated with subjective symptoms of neuropathy. There were 15 correlates of impaired perception of vibration among the AUD participants: Of these, age and volume of frontal precentral cortex were the most robust predictors. CONCLUSIONS This study supports CNS involvement in objective signs of neuropathy in AUD.
Collapse
Affiliation(s)
- Natalie M Zahr
- Neuroscience Program, (NMZ, KMP, AP), SRI International, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, (NMZ, KMP, AP, EVS), Stanford University School of Medicine, Stanford, California
| | - Kilian M Pohl
- Neuroscience Program, (NMZ, KMP, AP), SRI International, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, (NMZ, KMP, AP, EVS), Stanford University School of Medicine, Stanford, California
| | - Adolf Pfefferbaum
- Neuroscience Program, (NMZ, KMP, AP), SRI International, Menlo Park, California
- Department of Psychiatry and Behavioral Sciences, (NMZ, KMP, AP, EVS), Stanford University School of Medicine, Stanford, California
| | - Edith V Sullivan
- Department of Psychiatry and Behavioral Sciences, (NMZ, KMP, AP, EVS), Stanford University School of Medicine, Stanford, California
| |
Collapse
|
5
|
Endres D, Maier SJ, Ziegler C, Nickel K, Riering AN, Berger B, Lambeck J, Fritz M, Gläser B, Stock F, Dacko M, Lange T, Mader I, Domschke K, Tebartz van Elst L. Schizophrenia and Hereditary Polyneuropathy: PMP22 Deletion as a Common Pathophysiological Link? Front Psychiatry 2019; 10:270. [PMID: 31118906 PMCID: PMC6506456 DOI: 10.3389/fpsyt.2019.00270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 04/09/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Schizophrenic disorders are common and debilitating due to their symptoms, which can include delusions, hallucinations, and other negative symptoms. Organic forms can result from various cerebral disorders. In this paper, we discuss a potential association between schizophrenia and hereditary polyneuropathies (PNPs). Case presentation: We present the case of a 55-year-old female patient with chronically paranoid-hallucinatory schizophrenia, severe cognitive deficits since the age of 30, and comorbid repeated focal pressure neuropathies beginning at age 20. At the age of 35, genetic testing revealed a deletion on chromosome 17p12 covering the peripheral myelin protein 22 gene (PMP22), which led to the diagnosis of hereditary neuropathy with liability to pressure palsy (HNPP). Cerebral magnetic resonance imaging showed internal atrophy, magnetic resonance spectroscopy found alteration of the glutamate and myo-inositol levels in the anterior cingulate cortex, neuropsychological testing showed deficits in working memory and psychomotor speed, and electrophysiological testing detected signs of sensorimotor demyelinating PNP (accentuated in the legs). Conclusion: There may be an association between schizophrenia and HNPP. In observational studies, the deletion of interest (chromosome 17p12) was nearly 10 times more common in schizophreniform patients than in controls. This potential association could be pathophysiologically explained by the role of PMP22, which is mainly expressed in the peripheral nervous system. However, PMP22 mRNA and protein can also be found in the brain. PMP22 seems to play an important role in regulating cell growth and myelination, functions that are disturbed in schizophrenia. Such a connection obviously cannot be clarified on the basis of one case. Future studies should analyze whether patients with HNPP exhibit increased rates of psychotic disorders, and patients with schizophrenia and repeated focal pressure neuropathies should be examined for the PMP22 mutation. Alternatively, the co-occurrence of schizophrenia and HNPP could be coincidental.
Collapse
Affiliation(s)
- Dominique Endres
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon J Maier
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christiane Ziegler
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kathrin Nickel
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anne N Riering
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Berger
- Department of Neurology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam Fritz
- Department of Neurology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Birgitta Gläser
- Institute of Human Genetics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich Stock
- Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Michael Dacko
- Department of Radiology, Medical Physics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Lange
- Department of Radiology, Medical Physics, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Irina Mader
- Department of Neuroradiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Radiology, Clinic Schön Vogtareuth, Vogtareuth, Germany
| | - Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ludger Tebartz van Elst
- Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
6
|
Khadilkar SV, Yadav RS, Patel BA. Hereditary Liability to Pressure Palsies. Neuromuscul Disord 2018. [DOI: 10.1007/978-981-10-5361-0_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
7
|
Brandt AU, Meinert-Bohn E, Rinnenthal JL, Zimmermann H, Mikolajczak J, Oberwahrenbrock T, Papazoglou S, Pfüller CF, Schinzel J, Tackenberg B, Paul F, Hahn K, Bellmann-Strobl J. Afferent Visual Pathway Affection in Patients with PMP22 Deletion-Related Hereditary Neuropathy with Liability to Pressure Palsies. PLoS One 2016; 11:e0164617. [PMID: 27749933 PMCID: PMC5066968 DOI: 10.1371/journal.pone.0164617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 09/28/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The PMP22 gene encodes a protein integral to peripheral myelin. Its deletion leads to hereditary neuropathy with liability to pressure palsies (HNPP). PMP22 is not expressed in the adult central nervous system, but previous studies suggest a role in CNS myelin development. The objective of this study was to identify potential structural and functional alterations in the afferent visual system in HNPP patients. METHODS Twenty HNPP patients and 18 matched healthy controls (HC) were recruited in a cross-sectional study. Participants underwent neurological examination including visual acuity, visual evoked potential (VEP) examination, optical coherence tomography (OCT), and magnetic resonance imaging with calculation of brain atrophy, regarding grey and white matter, and voxel based morphometry (VBM), in addition answered the National Eye Institute's 39-item Visual Functioning Questionnaire (NEI-VFQ). Thirteen patients and 6 HC were additionally examined with magnetic resonance spectroscopy (MRS). RESULTS All patients had normal visual acuity, but reported reduced peripheral vision in comparison to HC in the NEI-VFQ (p = 0.036). VEP latency was prolonged in patients (P100 = 103.7±5.7 ms) in comparison to healthy subjects (P100 = 99.7±4.2 ms, p = 0.007). In OCT, peripapillary retinal nerve fiber layer thickness RNFL was decreased in the nasal sector (90.0±15.5 vs. 101.8±16.5, p = 0.013), and lower nasal sector RNFL correlated with prolonged VEP latency (Rho = -0.405, p = 0.012). MRS revealed reduced tNAA (731.4±45.4 vs. 814.9±62.1, p = 0.017) and tCr (373.8±22.2 vs. 418.7±31.1, p = 0.002) in the visual cortex in patients vs. HC. Whole brain volume, grey and white matter volume, VBM and metabolites in a MRS sensory cortex control voxel did not differ significantly between patients and HC. CONCLUSION PMP22 deletion leads to functional, metabolic and macro-structural alterations in the afferent visual system of HNPP patients. Our data suggest a functional relevance of these changes for peripheral vision, which warrants further investigation and confirmation.
Collapse
Affiliation(s)
- Alexander U. Brandt
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Elena Meinert-Bohn
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Leo Rinnenthal
- Institute of Neuropathology, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Hanna Zimmermann
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Janine Mikolajczak
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Timm Oberwahrenbrock
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Papazoglou
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Caspar F. Pfüller
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Schinzel
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Björn Tackenberg
- Department of Neurology, University of Giessen-Marburg, Marburg, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Katrin Hahn
- Department of Neurology, Charité –Universitätsmedizin Berlin, Berlin, Germany
| | - Judith Bellmann-Strobl
- NeuroCure Clinical Research Center, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité –Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|