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Deep Brain Stimulation: Complications and Management

  • Steven Lange
  • Sameah Haider
  • Adolfo Ramirez-Zamora
  • Julie G. Pilitsis
Chapter

Abstract

Deep brain stimulation (DBS) has shown efficacy in reducing motor symptoms and improving quality of life in patients with movement disorders. Despite expanding use of DBS in sick patients, complication rates remain low. Here we discuss the most common adverse events, including infection and hemorrhage, and complication avoidance strategies. Side effects caused by stimulation have been shown to be reversible with changing stimulation parameters. Further research must be done to better understand and evaluate complications of DBS in pediatric neurosurgery and in emerging applications.

Keywords

Deep brain stimulation Complications Hemorrhage Infection 

References

  1. 1.
    Allert N, Markou M, Miskiewicz AA, Nolden L, Karbe H. Electrode dysfunction in patients with deep brain stimulation: a clinical retrospective study. Acta Neurochir. 2011;153:2342–9.CrossRefGoogle Scholar
  2. 2.
    Bakay RAE, Smith AP. Deep brain stimulation: complications and attempts at avoiding them. Open Neurosurg J. 2011;4:42–52.CrossRefGoogle Scholar
  3. 3.
    Baltuch GH, Stern MB. Deep brain stimulation for Parkinson’s disease. Boca Raton: CRC; 2007.Google Scholar
  4. 4.
    Bhatia R, Dalton A, Richards M, Hopkins C, Aziz T, Nandi D. The incidence of deep brain stimulator hardware infection: the effect of change in antibiotic prophylaxis regimen and review of the literature. Br J Neurosurg. 2011;25(5):625–31.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Bjerknes S, Skogseid IM, Saehle T, Dietrichs E, Toft M. Surgical site infections after deep brain stimulation surgery: frequency, characteristics and management in a 10-year period. PLoS One. 2014;9(8):e105288.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Boviatsis EJ, Stavrinou LC, Themistocleous M, Kouyialis AT, Sakas DE. Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature. Acta Neurochir. 2010;152(12):2053–62.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Bronstein JM, Tagliati M, Alterman RL, Lozano AM, et al. Deep brain stimulation for Parkinson disease. Arch Neurol. 2011;68(2):165–71.PubMedCrossRefGoogle Scholar
  8. 8.
    Castrioto A, Lhommee E, Moro E, Krack P. Mood and behavioural effects of subthalamic stimulation in Parkinson’s disease. Lancet Neurol. 2014;13(3):287–305.PubMedCrossRefGoogle Scholar
  9. 9.
    Chan DTM, Zhu XL, Yeung JHM, Mok VCT, et al. Complications of deep brain stimulation: a collective review. Asian J Surg. 2009;32(4):258–63.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Chang EF, Cheng JS, Richardson RM, Lee C, Starr PA, Larson PS. Incidence and management of air embolisms during awake deep brain stimulation in a large clinical series. Stereotact Funct Neurosurg. 2011;89(2):76–82.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Chaudhry ZA, Najib U, Jacobs WC, Sheikh J, Simopoulos TT. Detailed analysis of allergic cutaneous reactions to spinal cord stimulator devices. J Pain Research. 2013;6:617–23.Google Scholar
  12. 12.
    Choi BS, Kim YH, Jeon SR. Vascular changes caused by deep brain stimulation using double-dose gadolinium-enhanced brain MRI. Neural Regen Res. 2014;9(3):276–9.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Deogaonkar M, Nazzaro JM, Machado A, Rezai A. Transient, symptomatic, post-operative, non-infectious hypodensity around the deep brain stimulation (DBS) electrode. J Clin Neurosci. 2011;18(7):910–5.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    DiLorenzo DJ, Danjovic J, Simpson RK, Takei H, Powell SZ. Neurohistopathological findings at the electrode-tissue Interface in long-term deep brain stimulation: systematic literature review, case report, and assessment of stimulation threshold safety. Neuromodulation. 2014;17:405–18.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Doshi PK. Long-term surgical and hardware-related complications of deep brain stimulation. Stereotact Funct Neurosurg. 2011;89:89–95.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Ellis TM, Foote KD, Fernandez HH, Sudhyadorm A, Rodriguez RL, Zeilman P, Jacobson CE, Okun MS. Reoperation for suboptimal outcomes after deep brain stimulation surgery. Neurosurgery. 2008;63(4):754–61.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Farris S, Giroux M. Retrospective review of factors leading to dissatisfaction with subthalamic nucleus deep brain stimulation during long-term management. Surg Neurol Int. 2013;4:69.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Fenoy AJ, Simpson RK. Management of device-related wound complications in deep brain stimulation surgery. J Neurosurg. 2012;116:1324–32.PubMedCrossRefGoogle Scholar
  19. 19.
    Fenoy AJ, Simpson RK. Risks of common complications in deep brain stimulation surgery: management and avoidance. J Neurosurg. 2014;120(1):132–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Fernandez FS, Alvarez Vega MA, Antuna Ramos A, Fernandez Gonzalez F, Lozano AB. Lead fractures in deep brain stimulation during long-term follow-up. Parkinsons Dis. 2010; Article ID 409356, 4 pp.Google Scholar
  21. 21.
    Fields JA, Troster AI. Cognitive outcomes after deep brain stimulation for Parkinson’s disease: a review of initial studies and recommendations for future research. Brain Cogn. 2000;42:268–93.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Follett KA, Weaver FM, Stern M, Hur K, et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson’s disease. N Engl J Med. 2010;362(22):2077–91.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Franzini A, Cordella R, Messina G, Marras CE, et al. Deep brain stimulation for movement disorders: considerations of 276 consecutive patients. J Neural Transm. 2011;118:1497–510.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Funkiewiez A, Ardouin C, Caputo E, Krack P, Fraix V, et al. Long term effects of bilateral subthalamic nucleus stimulation on cognitive function, mood, and behavior in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2004;75:834–9.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Hariz MI. Complications of deep brain stimulation surgery. Mov Disord. 2002;17(3):S162–6.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Hariz MI. Deep brain stimulation: new techniques. Parkinsonism Relat Disord. 2014;20S1:S192–6.CrossRefGoogle Scholar
  27. 27.
    Hariz MI, Johansson F. Hardware failure in parkinsonian patients with chronic subthalamic nucleus stimulation is a medical emergency. Mov Disord. 2001;16:166–8.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Hooper AK, Okun MS, Foote KD, Haq IU, et al. Venous air embolism in deep brain stimulation. Stereotact Funct Neurosurg. 2009;87(1):25–30.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Itakura T. Deep brain stimulation for neurological disorders: theoretical background. New York: Springer; 2015.CrossRefGoogle Scholar
  30. 30.
    Joint C, Nandi D, Chir M, Parkin S, Gregory R, Aziz T. Hardware-related problems of deep brain stimulation. Mov Disord. 2002;17(3):S175–80.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol. 2005;26(12):916–22.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Kenney C, Simpson R, Hunter C, Ondo W, Almaguer M, Davidson A, Jankovic J. Short-term and long-term safety of deep brain stimulation in the treatment of movement disorders. J Neurosurg. 2007;106:621–5.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Kocabicak E, Yasin T. Deep brain stimulation of the subthalamic nucleus in Parkinson’s disease: surgical technique, tips, tricks and complications. Clin Neurol Neurosurg. 2013;115(11):2318–23.PubMedCrossRefGoogle Scholar
  34. 34.
    Koller WC, Lyons KE, Wilkinson SB, Troster AI, Pahwa R. Long-term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor. Mov Disord. 2011;16(3):464–8.CrossRefGoogle Scholar
  35. 35.
    Krack P, Poepping M, Weinert D, Schrader B, Deuschl G. Thalamic, pallidal, or subthalamic surgery for Parkinson’s disease? J Neurol. 2000;247(2):122–34.Google Scholar
  36. 36.
    Kramer DR, Halpern CH, Buonacore DL, McGill KR, et al. Best surgical practices: a stepwise approach to the University of Pennsylvania deep brain stimulation protocol. Neurosurg Focus. 2010;29(2):E3.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Kumar K, Toth C, Nath RK, Laing P. Epidural spinal cord stimulation for treatment of chronic pain – some predictors of success. A 15-year experience. Surg Neurol. 1998;50(2):110–20.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Lanotte M, Verna G, Panciani PP, Taveggia A, et al. Management of skin erosion following deep brain stimulation. Neurosurg Rev. 2009;32:111–5.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Larson PS. Deep brain stimulation for movement disorders. Neurotherapeutics. 2014;11(3):465–74.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Liu JK, Soliman H, Machado A, Deogaonkar M, Rezai AR. Intracranial hemorrhage after removal of deep brain stimulation electrodes. J Neurosurg. 2012;116(3):525–8.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Lyons KE, Wilkinson SB, Overman J, Pahwa R. Surgical and hardware complications of subthalamic stimulation: a series of 160 procedures. Neurology. 2004;63(4):612–6.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Maiser F, Lewis CJ, Horstkoetter N, Eggers C, Kalbe E, et al. Patients’ expectations of deep brain stimulation, and subjective perceived outcome related to clinical measures in Parkinson’s disease: a mixed-method approach. J Neurol Neurosrug Psychiatry. 2013;84:1273–81.CrossRefGoogle Scholar
  43. 43.
    Mangram AJ, Horan TC, Pearson MI, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection. Am J Infect Control. 1999;27:97–132.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Martinez-Ramirez D, Morishita T, Zeilman PR, Peng-Chen Z, Foote KD, et al. Atrophy and other potential factors affecting long term deep brain stimulation response: a case series. PLoS One. 2014;14(10):e111561.CrossRefGoogle Scholar
  45. 45.
    Mehanna R, Lai EC. Deep brain stimulation in Parkinson’s disease. Transl Neurodegener. 2013;2:22.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Morishita T, Okun MS, Burdick A, Jacobson CE, Foote KD. Cerebral venous infarction: a potentially avoidable complication of deep brain stimulation surgery. Neuromodulation. 2013;16(5):407–13.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Obeso JA, Guridi J, Rodriguez-Oroz MC, Agid Y, et al. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease. N Engl J Med. 2001;345:956–63.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Oh MY, Abosch A, Kim SH, Lang AE, Lozano AM. Long-term hardware-related complications of deep brain stimulation. Neurosurgery. 2002;50(6):1268–76.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Okun MS, Zeilman PR. Parkinson’s disease: guide to deep brain stimulation therapy: National Parkinson Foundation. Hagerstown, MD: 2014.Google Scholar
  50. 50.
    Paffi A, Camera F, Apollonio F, d’Inzeo G, Liberti M. Numerical characterization of intraoperative and chronic electrodes in deep brain stimulation. Front Comput Neurosci. 2015;9:2.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Park JH, Chung SJ, Lee CS, Jeon SR. Analysis of hemorrhagic risk factors during deep brain stimulation surgery for movement disorders: comparison of the circumferential paired and multiple electrode insertion methods. Acta Neurochir. 2011;153:1573–8.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Patel NV, Barrese J, DiTota RJ, Hargreaves EL. Deep brain stimulation lead fixation after Stimloc failure. J Clin Neurosci. 2012;19(12):1715–8.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Perestelo-Perez L, Rivero-Santana A, Perez-Ramos J, Serrano-Perez P, Panetta J, Hilarion P. Deep brain stimulation in Parkinson’s disease: meta-analysis of randomized control trials. J Neurol. 2014;261:2051–60.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Piacentino M, Zambon G, Pilleri M, Bartolomei L. Comparison of the incidence of intracranial hemorrhage in two different planning techniques for stereotactic electrode placement in the deep brain stimulation. J Neurosurg Sci. 2013;57:63–7.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Pilitsis JG, Metman LV, Toleikis JR, Hughes LE, Sani SB, Bakay RAE. Factors involved in long-term efficacy of deep brain stimulation of the thalamus for essential tremor. J Neurosurg. 2008;109(4):640–6.PubMedCrossRefGoogle Scholar
  56. 56.
    Pouratian N, Reames DL, Frysinger R, Elias WJ. Comhensive analysis of risk factors for seizures after deep brain stimulation surgery. J Neurosurg. 2011;115(2):310–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Ramirez-Zamora A, Kahn M, Campbell J, DeLaCruz P, Pilitsis JG. Interleaved programming of subthalamic deep brain stimulation to avoid adverse effects and preserve motor benefit in Parkinson’s disease. J Neurol. 2015;262(3):578–84.PubMedCrossRefGoogle Scholar
  58. 58.
    Ramirez-Zamora A, Levine D, Sommer DB, Dalfino J, Novak P, Pilitsis JG. Intraparenchymal cyst development after deep brain stimulator placement. Stereotact Funct Neurosurg. 2013;91(5):338–41.PubMedCrossRefGoogle Scholar
  59. 59.
    Ranson M, Pope J, Deer T. Reducing risks and complications of interventional pain procedures. New York: Saunders; 2012.Google Scholar
  60. 60.
    Sansur CA, Frysinger RC, Pouratian N, Fu KM, Bittl M, Oskouian RJ, Laws ER, Elias WJ. Incidence of symptomatic hemorrhage after stereotactic electrode placement. J Neurosurg. 2007;107:998–1003.PubMedCrossRefGoogle Scholar
  61. 61.
    Seijo F, Alvarez de Eulate Beramendi S, Santamarta Liebana E, Lozano Aragoneses B, Saiz Ayala A, Fernandez de Leon R, Alvarez Vega MA. Surgical adverse events of deep brain stimulation in the subthalamic nucleus of patients with Parkinson’s disease: the learning curve and the pitfalls. Acta Neurochir. 2014;156:1505–12.PubMedCrossRefGoogle Scholar
  62. 62.
    Sestini S, Ramat S, Formiconi AR, Ammannati F, Sorbi S, Pupi A. Brain networks underlying the clinical effects of long-term subthalamic stimulation for Parkinson’s disease: a 4-year follow-up study with rCBF SPECT. J Nucl Med. 2005;46(9):1444–54.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Shipton EA. Movement disorders and neuromodulation. Neurol Res Int. 2012;2012. Article ID 309431.  https://doi.org/10.1155/2012/309431.CrossRefGoogle Scholar
  64. 64.
    Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hosp Epidemiol. 2013;34:1–14.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Sillay KA, Larson PS, Starr PA. Deep brain stimulation hardware-related infections: incidence and management in a large series. Neurosurgery. 2008;62:360–7.CrossRefGoogle Scholar
  66. 66.
    Sixel-Doring F, Trenkwalder C, Kappus C, Hellwig D. Skin complications in deep brain stimulation for Parkinson’s disease: frequency, time course, and risk factors. Acta Neurochir. 2010;152:195–200.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Sun DA, Yu H, Spooner J, Tatsas AD, Davis T, Abel TW, Kao C, Konrad PE. Postmortem analysis following 71 months of deep brain stimulation of the subthalamic nucleus for Parkinson disease. J Neurosurg. 2008;109(2):325–9.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Taverner MG. A case of an allergic reaction to a spinal cord stimulator: identification of the antigen with epicutaneous patch testing, allowing successful reimplantation. Neuromodulation. 2013;16:595–9.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Tong F, Ramirez-Zamora A, Gee L, Pilitsis J. Unusual complications of deep brain stimulation. Neurosurg Rev. 2014;38:245–52.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Vedam-Mai V, Yachnis A, Ullman M, Javedan SP, Okun MS. Postmortem observation of collagenous lead tip region fibrosis as a rare complication of DBS. Mov Disord. 2012;27(4):565–9.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Videnovic A, Metman LV. Deep brain stimulation for Parkinson’s disease: prevalence of adverse events and need for standardized reporting. Mov Disord. 2008;23(3):343–9.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Voges J, Koulousakis A, Sturm V. Deep brain stimulation for Parkinson’s disease. Acta Neurochir Suppl. 2007;97:171–84.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Voon V, Krack P, Lang AE, Lozano AM, Dujardin K, et al. A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson’s disease. Brain. 2008;131(10):2720–8.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Voon V, Kubu C, Krack P, Houeto JL, Troster AI. Deep brain stimulation: neuropsychological and neuropsychiatric issues. Mov Disord. 2006;21(14):S305–26.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Weaver FM, Follett KA, Stern M, Luo P, Harris CL, et al. Randomized trial for deep brain stimulation for Parkinson disease: thirty-six month outcomes. Neurology. 2012;79(1):55–65.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Weintraub D, Juda DE, Carlson K, Luo P, Sagher O, et al. Suicide ideation and behaviors after STN and GPi DBS surgery for Parkinson’s disease: results from a randomised, controlled trial. J Neurol Neurosurg Psychiatry. 2013;84(10):1113–8.PubMedPubMedCentralCrossRefGoogle Scholar
  77. 77.
    Wharen RE, Putzke JD, Uitti RJ. Deep brain stimulation lead fixation: a comparative study of the Navigus and Medtronic burr hole fixation device. Clin Neurol Neurosurg. 2005;107(5):393–5.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Williams AE, Arzola GM, Strutt AM, Simpson R, Jankovic J, York MK. Cognitive outcome and reliable change indices two years following bilateral subthalamic nucleus deep brain stimulation. Parkinsonism Relat Diord. 2011;17(5):321–7.CrossRefGoogle Scholar
  79. 79.
    Witt K, Daniels C, Reiff J, Krack P, et al. Neuropsychological and psychiatric changes after deep brain stimulation for Parkinson’s disease: a randomised, multicentre study. Lancet Neurol. 2008;7:605–14.PubMedCrossRefPubMedCentralGoogle Scholar
  80. 80.
    Xiaowu H, Xiufeng J, Xiaoping Z, Bin H, Laixing W, Yiqun C, Jinchuan L, Aiquo J, Jianmin L. Risks of intracranial hemorrhage in patients with Parkinson’s disease receiving deep brain stimulation and ablation. Parkinsonism Relat Disord. 2010;16(2):96–100.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Yamanaka T, Ishii F, Umemura A, Miyata M, Horiba M, et al. Temporary deterioration of executive function after subthalamic deep brain stimulation in Parkinson’s disease. Clin Neurol Neurosurg. 2012;114:347–51.PubMedCrossRefPubMedCentralGoogle Scholar
  82. 82.
    York MK, Wilde EA, Simpson R, Jankovic J. Relationship between neuropsychological outcome and DBS surgery trajectory and electrode location. J Neuro Sci. 2009;287:159–71.CrossRefGoogle Scholar
  83. 83.
    Zangaglia R, Pacchetti C, Pasotti C, Mancini F, Servello D, et al. Deep brain stimulation and cognitive functions in Parkinson’s disease: a three-year controlled study. Mov Disord. 2009;24(11):1621–8.PubMedCrossRefPubMedCentralGoogle Scholar
  84. 84.
    Zibly Z, Sharma M, Shaw A, Yeremeyeva E, Deogaonkar M, Rezai A. Deep brain stimulation (DBS), lead migration, and the stimloc cap: complication avoidance. Neurol India. 2014;62(6):703–4.PubMedCrossRefPubMedCentralGoogle Scholar
  85. 85.
    Zrinzo L, Yoshida F, Hariz MI, Thornton J, Foltynie T, Yousry TA, Limousin P. Clinical safety of brain magnetic resonance imaging with implanted deep brain stimulation hardware: large case series and review of the literature. World Neurosurg. 2011;76(1–2):164–72.PubMedCrossRefPubMedCentralGoogle Scholar
  86. 86.
    Chin LS, Regine WF. Principles and practice of stereotactic radiosurgery. New York: Springer; 2015.CrossRefGoogle Scholar
  87. 87.
    Alterman RL, Tagliati M. Deep brain stimulation for dystonia: patient selection, surgical technique, and programming. Open Neurosurg J. 2011;4(1-M2):29–35.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Steven Lange
    • 1
  • Sameah Haider
    • 1
  • Adolfo Ramirez-Zamora
    • 2
  • Julie G. Pilitsis
    • 1
  1. 1.Department of NeurosurgeryAlbany Medical CenterAlbanyUSA
  2. 2.Department of NeurologyUniversity of FloridaGainesvilleUSA

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