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Cardioversion-Responsive Ventriculoatrial Shunt Malfunction Precipitated by Atrial Fibrillation
Case Report
Cardioversion-Responsive Ventriculoatrial Shunt Malfunction Precipitated by Atrial Fibrillation Wi Jin Kim1,2, Georgios Zenonos1, Michael M. McDowell1, Paul A. Gardner1, Johnathan A. Engh1
Key words Atrial-fibrillation - Cardioversion - Ventriculoatrial shunt - Ventriculoatrial shunt malfunction -
Abbreviations and Acronyms AF: Atrial fibrillation CSF: Cerebrospinal fluid CT: Computed tomography VA: Ventriculoatrial
- BACKGROUND:
Ventriculoatrial shunts are common alternatives for patients who cannot tolerate ventriculoperitoneal shunts. The majority of ventriculoatrial shunt malfunctions are related to mechanical problems. We report an interesting case of ventriculoatrial shunt malfunction due to elevated central venous pressure from new-onset atrial fibrillation.
- METHODS:
After the patient was confirmed to have ventriculomegaly, he was taken to the operating room for exploration of his ventriculoatrial shunt; there were no obstructions. Subsequently, the patient was cardioverted to normal sinus rhythm for his new onset atrial fibrillation.
From the 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- RESULTS:
To whom correspondence should be addressed: Johnathan A. Engh, M.D. [E-mail: [email protected]]
- CONCLUSIONS:
The clinical syndrome and ventriculomegaly both resolved after the patient’s atrial fibrillation was corrected with chemical cardioversion.
The cause of this patient’s VA shunt malfunction was likely associated with his new onset atrial fibrillation.
Citation: World Neurosurg. (2018) 114:348-351. https://doi.org/10.1016/j.wneu.2018.03.071 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
INTRODUCTION Successful cerebrospinal fluid (CSF) diversion can be difficult to achieve in patients with complex medical comorbidities. Although the peritoneal cavity is usually a preferred drainage target for ventricular shunts because of the large absorptive surface area, this approach may be rendered unfeasible secondary to active infections, intraabdominal pathology, or scarring from surgical procedures. Both ventriculopleural shunts and ventriculoatrial (VA) shunts are common alternatives in such patients. VA shunts pose a unique set of challenges related to the cardiopulmonary system. We present a unique case in which a distal VA shunt malfunction was precipitated by new-onset atrial fibrillation (AF). The malfunction resolved after successful cardioversion and was confirmed with ventricular collapse on subsequent computed tomography (CT) scans.
348
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CASE PRESENTATION A 50-year-old man with a VA shunt that was placed for congenital hydrocephalus presented with a chief complaint of 1 week of blurred vision. His medical history was notable for numerous ventriculoperitoneal shunt revisions in the past, eventually leading to a VA shunt several years before this presentation. Figure 1 shows an axial CT scan of the head of our patient 4 months before presentation, when it was determined he was not in shunt failure. The patient denied headaches, diplopia, confusion, motor/sensory alterations, or other neurologic complaints. He reported that he had experienced similar symptoms of blurry vision during prior episodes of shunt malfunction. On further questioning, the patient reported having mild shortness of breath, dyspnea on exertion, and tremors for several weeks. An electrocardiogram was ordered at the time as part of his preoperative workup, which revealed AF. The patient denied having any history of cardiac disease, and an electrocardiogram from his last presentation demonstrated normal sinus rhythm. On examination, he was alert and oriented to self, location, and time. His pupils were equal, round, and reactive to light; his
extraocular movements were intact without any signs of up-gaze palsy. His motor and sensory examination was benign. His lungs were clear to auscultation bilaterally, and his heart rhythm was irregular without any discernable murmurs on auscultation. Cardiac telemetry confirmed that the patient was in AF. A shunt series was unremarkable for migration or any other catheter abnormalities (Figure 2), but a CT of the head disclosed a substantial increase in ventricular caliber (Figure 3). The patient was subsequently taken to the operating room for shunt exploration. After the shunt reservoir was exposed with a small incision, the Rickham reservoir was disconnected from the ventricular catheter. This led to brisk egress of cerebrospinal fluid from the proximal ventricular catheter and appropriate flow through the valve when tested distally. The Rickham reservoir and ventricular catheter were reconnected, and then a small incision was made in the parietal region to expose the distal catheter. Amputation of the catheter at this site again showed brisk egress of CSF from the proximal part and was therefore clamped with a protected hemostat. Interestingly, there was backflow of venous blood coming up the distal
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.03.071
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 1. (AeC) Computed tomography head of patient 4 months before presentation depicting axial sequences at the level of the lateral ventricles.
part of the amputated catheter from the jugular vein. A manometer and a blunt stylet were inserted to determine the pressure from the distal catheter. The pressure was found to be 8 cm H2O. This measurement was made at the level of the external auditory canal, which due to our positioning at the time was approximately 10 cm above the level of the right atrium. This translated to an estimated central venous pressure of approximately 18 cm of water. Given that normal central venous pressures range from 1e8 cm H2O,1 this finding suggested that venous back-
pressure from the patient’s cardiac arrhythmia was the cause of his shunt failure. Subsequently, the amputated ends of the catheter were reattached using a male-to-male connector, incisions were closed, and the patient recovered from the operation without any complications. Postoperatively, cardiology was consulted to help with the management of the patient’s arrhythmia. On the following day, the patient was chemically cardioverted to normal sinus rhythm with amiodarone. The procedure was visualized using transesophageal echocardiography. The left atrial
Figure 2. Plain radiographs depicting normal ventriculoatrial shunt placement and course. (A) Anteroposterior (AP) radiograph of the skull. (B)
WORLD NEUROSURGERY 114: 348-351, JUNE 2018
appendage emptying velocity at that time was measured to be 16.6 cm/sec (normal >40 cm/sec). Normal sinus rhythm was restored and maintained with standing doses of amiodarone. A follow-up head CT scan was obtained 24 hours after the cardioversion, which showed improving ventricular caliber (Figure 4). The patient reported improvement of blurry vision and therefore was subsequently discharged in stable condition. At a follow-up appointment 2 weeks after discharge, the patient received a new head CT scan, which again demonstrated
Lateral radiograph of the skull. (C) AP radiograph of the cervical spine. (D) AP radiograph of the chest.
www.WORLDNEUROSURGERY.org
349
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 3. (AeC) Computed tomography head of patient on presentation depicting axial sequences at the level of the lateral ventricles.
increased ventricular caliber (Figure 5). Of note, even before his 2-week postoperative appointment, the patient subsequently called our office to say that he had another episode of AF leading to recurrence of blurry vision and prompting an emergency department visit. The patient was again cardioverted, and his symptoms resolved, this time without subsequent relapse.
DISCUSSION Clinical development of shunt malfunction is generally related to either obstruction of flow or increased resistance to flow within the shunt system. The most common culprit is ventricular catheter obstruction followed by valvular obstruction. True distal catheter obstruction is far more rare and is classically related to debris within the distal catheter tip or an increase of the
resistance to flow of fluid from the distal catheter.2,3 One unique feature of VA shunts relative to ventriculoperitoneal shunts or ventriculopleural shunts is that VA shunts are placed into the venous system as opposed to a potential space; therefore increases of central venous pressure can potentially obstruct shunt flow. VA shunts are frequently placed in patients in whom the peritoneum is not an
Figure 4. (AeC) Computed tomography head 24 hours subsequent to cardioversion depicting axial sequences at the level of the lateral ventricles.
350
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.03.071
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 5. (AeC) Computed tomography head 2 weeks after initial presentation depicting axial sequences at the level of the lateral ventricles.
acceptable reservoir for the diversion of CSF. All ventricular shunts are susceptible to malfunction due to obstruction, disconnection, and infection. However, patients with VA shunts are at risk for different complications than those with other types of shunts, the most unique of which are cardiopulmonary complications. Our case report describes an instance in which new-onset AF was the source of the shunt malfunction without any obvious change in shunt patency or location. Because AF has been shown to increase central venous pressure,4 we hypothesize that the patient’s AF prevented CSF flow down into the right atrium and caused clinical malfunction. As described earlier, the estimated central venous pressure in our case was estimated to be approximately 18 cm H2O (normal 5e10 cm H2O). Given that shunt valves work with pressure gradients between the proximal and distal catheters rather than absolute pressures, elevation of the distal pressure did not allow the elevated intracranial pressures to overcome the valve’s gradient and drain CSF. Cardioverting the patient to normal sinus rhythm effectively reduced the central venous pressure and reestablished CSF flow into a lower-pressure reservoir. The association of the effects of AF with ventriculomegaly and shunt failure symptoms was reaffirmed with the breakthrough episode of AF leading to shunt failure and
resolution of both with restoration of normal sinus rhythm. Whether the presence of a shunt was the cause of AF in this patient is difficult to determine. Costa et al5 have shown that high central venous pressures can lead to greater atrial distention and therefore a higher incidence of AF. However, it is unlikely that the additional volume to the right atrium from the VA shunt predisposed this patient to developing AF, as the additional CSF being produced at a rate of 0.33 mL per hour is unlikely to distend the right atrium considering its rate of blood flow. It is also possible that the atrial catheter could have abnormally positioned and acted as a foci of arrhythmia by irritating the chamber wall. Given that both the pleural cavity and peritoneum of the patient had previously failed, we chose not to convert the shunt to a ventriculopleural or ventriculoperitoneal shunt.
presence of VA shunt contributed to the development of AF. REFERENCES 1. Meyer TE. Examination of the jugular venous pulse. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.; 2018. 2. Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children [e-pub ahead of print]. Pediatr Neurosurg. https://doi. org/10.1159/000452840, accessed March 2, 2017. 3. Kashyap S, Ghanchi H, Minasian T, Dong F, Miulli D. Abdominal pseudocyst as a complication of ventriculoperitoneal shunt placement: review of the literature and a proposed algorithm for treatment using 4 illustrative cases. Surg Neurol Int. 2017;10:78. 4. Wasmund S, Li JM, Page R, Joglar JA, Kowal RC, Smith ML, et al. Effect of atrial fibrillation and an irregular ventricular response on sympathetic nerve activity in human subjects. Circulation. 2003;107:2011-2015. 5. Costa MACD, Lirani W, Wippich AC, Lopes L, Tolentino ES, Zampar B, et al. Comparison of two central venous pressure control strategies to prevent atrial fibrillation after coronary artery bypass grafting. Arg Bras Cardiol. 2017;108:297-303.
CONCLUSION To our knowledge, we are the first to report AF as the cause of VA shunt malfunction. Elevated central venous pressure from AF can limit CSF drainage from the cerebral ventricles into the right atrium and lead to shunt malfunction in patients with VA shunts. This cause of VA shunt failure is responsive to cardioversion to normal sinus rhythm. It is unclear if the
WORLD NEUROSURGERY 114: 348-351, JUNE 2018
Conflict of interest statement: The authors have no disclosures to report. Received 16 November 2017; accepted 9 March 2018 Citation: World Neurosurg. (2018) 114:348-351. https://doi.org/10.1016/j.wneu.2018.03.071 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
351
Cardioversion-Responsive Ventriculoatrial Shunt Malfunction Precipitated by Atrial Fibrillation Wi Jin Kim1,2, Georgios Zenonos1, Michael M. McDowell1, Paul A. Gardner1, Johnathan A. Engh1
Key words Atrial-fibrillation - Cardioversion - Ventriculoatrial shunt - Ventriculoatrial shunt malfunction -
Abbreviations and Acronyms AF: Atrial fibrillation CSF: Cerebrospinal fluid CT: Computed tomography VA: Ventriculoatrial
- BACKGROUND:
Ventriculoatrial shunts are common alternatives for patients who cannot tolerate ventriculoperitoneal shunts. The majority of ventriculoatrial shunt malfunctions are related to mechanical problems. We report an interesting case of ventriculoatrial shunt malfunction due to elevated central venous pressure from new-onset atrial fibrillation.
- METHODS:
After the patient was confirmed to have ventriculomegaly, he was taken to the operating room for exploration of his ventriculoatrial shunt; there were no obstructions. Subsequently, the patient was cardioverted to normal sinus rhythm for his new onset atrial fibrillation.
From the 1Department of Neurological Surgery, University of Pittsburgh Medical Center; and 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- RESULTS:
To whom correspondence should be addressed: Johnathan A. Engh, M.D. [E-mail: [email protected]]
- CONCLUSIONS:
The clinical syndrome and ventriculomegaly both resolved after the patient’s atrial fibrillation was corrected with chemical cardioversion.
The cause of this patient’s VA shunt malfunction was likely associated with his new onset atrial fibrillation.
Citation: World Neurosurg. (2018) 114:348-351. https://doi.org/10.1016/j.wneu.2018.03.071 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
INTRODUCTION Successful cerebrospinal fluid (CSF) diversion can be difficult to achieve in patients with complex medical comorbidities. Although the peritoneal cavity is usually a preferred drainage target for ventricular shunts because of the large absorptive surface area, this approach may be rendered unfeasible secondary to active infections, intraabdominal pathology, or scarring from surgical procedures. Both ventriculopleural shunts and ventriculoatrial (VA) shunts are common alternatives in such patients. VA shunts pose a unique set of challenges related to the cardiopulmonary system. We present a unique case in which a distal VA shunt malfunction was precipitated by new-onset atrial fibrillation (AF). The malfunction resolved after successful cardioversion and was confirmed with ventricular collapse on subsequent computed tomography (CT) scans.
348
www.SCIENCEDIRECT.com
CASE PRESENTATION A 50-year-old man with a VA shunt that was placed for congenital hydrocephalus presented with a chief complaint of 1 week of blurred vision. His medical history was notable for numerous ventriculoperitoneal shunt revisions in the past, eventually leading to a VA shunt several years before this presentation. Figure 1 shows an axial CT scan of the head of our patient 4 months before presentation, when it was determined he was not in shunt failure. The patient denied headaches, diplopia, confusion, motor/sensory alterations, or other neurologic complaints. He reported that he had experienced similar symptoms of blurry vision during prior episodes of shunt malfunction. On further questioning, the patient reported having mild shortness of breath, dyspnea on exertion, and tremors for several weeks. An electrocardiogram was ordered at the time as part of his preoperative workup, which revealed AF. The patient denied having any history of cardiac disease, and an electrocardiogram from his last presentation demonstrated normal sinus rhythm. On examination, he was alert and oriented to self, location, and time. His pupils were equal, round, and reactive to light; his
extraocular movements were intact without any signs of up-gaze palsy. His motor and sensory examination was benign. His lungs were clear to auscultation bilaterally, and his heart rhythm was irregular without any discernable murmurs on auscultation. Cardiac telemetry confirmed that the patient was in AF. A shunt series was unremarkable for migration or any other catheter abnormalities (Figure 2), but a CT of the head disclosed a substantial increase in ventricular caliber (Figure 3). The patient was subsequently taken to the operating room for shunt exploration. After the shunt reservoir was exposed with a small incision, the Rickham reservoir was disconnected from the ventricular catheter. This led to brisk egress of cerebrospinal fluid from the proximal ventricular catheter and appropriate flow through the valve when tested distally. The Rickham reservoir and ventricular catheter were reconnected, and then a small incision was made in the parietal region to expose the distal catheter. Amputation of the catheter at this site again showed brisk egress of CSF from the proximal part and was therefore clamped with a protected hemostat. Interestingly, there was backflow of venous blood coming up the distal
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.03.071
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 1. (AeC) Computed tomography head of patient 4 months before presentation depicting axial sequences at the level of the lateral ventricles.
part of the amputated catheter from the jugular vein. A manometer and a blunt stylet were inserted to determine the pressure from the distal catheter. The pressure was found to be 8 cm H2O. This measurement was made at the level of the external auditory canal, which due to our positioning at the time was approximately 10 cm above the level of the right atrium. This translated to an estimated central venous pressure of approximately 18 cm of water. Given that normal central venous pressures range from 1e8 cm H2O,1 this finding suggested that venous back-
pressure from the patient’s cardiac arrhythmia was the cause of his shunt failure. Subsequently, the amputated ends of the catheter were reattached using a male-to-male connector, incisions were closed, and the patient recovered from the operation without any complications. Postoperatively, cardiology was consulted to help with the management of the patient’s arrhythmia. On the following day, the patient was chemically cardioverted to normal sinus rhythm with amiodarone. The procedure was visualized using transesophageal echocardiography. The left atrial
Figure 2. Plain radiographs depicting normal ventriculoatrial shunt placement and course. (A) Anteroposterior (AP) radiograph of the skull. (B)
WORLD NEUROSURGERY 114: 348-351, JUNE 2018
appendage emptying velocity at that time was measured to be 16.6 cm/sec (normal >40 cm/sec). Normal sinus rhythm was restored and maintained with standing doses of amiodarone. A follow-up head CT scan was obtained 24 hours after the cardioversion, which showed improving ventricular caliber (Figure 4). The patient reported improvement of blurry vision and therefore was subsequently discharged in stable condition. At a follow-up appointment 2 weeks after discharge, the patient received a new head CT scan, which again demonstrated
Lateral radiograph of the skull. (C) AP radiograph of the cervical spine. (D) AP radiograph of the chest.
www.WORLDNEUROSURGERY.org
349
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 3. (AeC) Computed tomography head of patient on presentation depicting axial sequences at the level of the lateral ventricles.
increased ventricular caliber (Figure 5). Of note, even before his 2-week postoperative appointment, the patient subsequently called our office to say that he had another episode of AF leading to recurrence of blurry vision and prompting an emergency department visit. The patient was again cardioverted, and his symptoms resolved, this time without subsequent relapse.
DISCUSSION Clinical development of shunt malfunction is generally related to either obstruction of flow or increased resistance to flow within the shunt system. The most common culprit is ventricular catheter obstruction followed by valvular obstruction. True distal catheter obstruction is far more rare and is classically related to debris within the distal catheter tip or an increase of the
resistance to flow of fluid from the distal catheter.2,3 One unique feature of VA shunts relative to ventriculoperitoneal shunts or ventriculopleural shunts is that VA shunts are placed into the venous system as opposed to a potential space; therefore increases of central venous pressure can potentially obstruct shunt flow. VA shunts are frequently placed in patients in whom the peritoneum is not an
Figure 4. (AeC) Computed tomography head 24 hours subsequent to cardioversion depicting axial sequences at the level of the lateral ventricles.
350
www.SCIENCEDIRECT.com
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.03.071
CASE REPORT WI JIN KIM ET AL.
ATRIAL FIBRILLATION AND CARDIOVERSION-RESPONSIVE VENTRICULOATRIAL SHUNT MALFUNCTION
Figure 5. (AeC) Computed tomography head 2 weeks after initial presentation depicting axial sequences at the level of the lateral ventricles.
acceptable reservoir for the diversion of CSF. All ventricular shunts are susceptible to malfunction due to obstruction, disconnection, and infection. However, patients with VA shunts are at risk for different complications than those with other types of shunts, the most unique of which are cardiopulmonary complications. Our case report describes an instance in which new-onset AF was the source of the shunt malfunction without any obvious change in shunt patency or location. Because AF has been shown to increase central venous pressure,4 we hypothesize that the patient’s AF prevented CSF flow down into the right atrium and caused clinical malfunction. As described earlier, the estimated central venous pressure in our case was estimated to be approximately 18 cm H2O (normal 5e10 cm H2O). Given that shunt valves work with pressure gradients between the proximal and distal catheters rather than absolute pressures, elevation of the distal pressure did not allow the elevated intracranial pressures to overcome the valve’s gradient and drain CSF. Cardioverting the patient to normal sinus rhythm effectively reduced the central venous pressure and reestablished CSF flow into a lower-pressure reservoir. The association of the effects of AF with ventriculomegaly and shunt failure symptoms was reaffirmed with the breakthrough episode of AF leading to shunt failure and
resolution of both with restoration of normal sinus rhythm. Whether the presence of a shunt was the cause of AF in this patient is difficult to determine. Costa et al5 have shown that high central venous pressures can lead to greater atrial distention and therefore a higher incidence of AF. However, it is unlikely that the additional volume to the right atrium from the VA shunt predisposed this patient to developing AF, as the additional CSF being produced at a rate of 0.33 mL per hour is unlikely to distend the right atrium considering its rate of blood flow. It is also possible that the atrial catheter could have abnormally positioned and acted as a foci of arrhythmia by irritating the chamber wall. Given that both the pleural cavity and peritoneum of the patient had previously failed, we chose not to convert the shunt to a ventriculopleural or ventriculoperitoneal shunt.
presence of VA shunt contributed to the development of AF. REFERENCES 1. Meyer TE. Examination of the jugular venous pulse. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.; 2018. 2. Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal fluid shunting complications in children [e-pub ahead of print]. Pediatr Neurosurg. https://doi. org/10.1159/000452840, accessed March 2, 2017. 3. Kashyap S, Ghanchi H, Minasian T, Dong F, Miulli D. Abdominal pseudocyst as a complication of ventriculoperitoneal shunt placement: review of the literature and a proposed algorithm for treatment using 4 illustrative cases. Surg Neurol Int. 2017;10:78. 4. Wasmund S, Li JM, Page R, Joglar JA, Kowal RC, Smith ML, et al. Effect of atrial fibrillation and an irregular ventricular response on sympathetic nerve activity in human subjects. Circulation. 2003;107:2011-2015. 5. Costa MACD, Lirani W, Wippich AC, Lopes L, Tolentino ES, Zampar B, et al. Comparison of two central venous pressure control strategies to prevent atrial fibrillation after coronary artery bypass grafting. Arg Bras Cardiol. 2017;108:297-303.
CONCLUSION To our knowledge, we are the first to report AF as the cause of VA shunt malfunction. Elevated central venous pressure from AF can limit CSF drainage from the cerebral ventricles into the right atrium and lead to shunt malfunction in patients with VA shunts. This cause of VA shunt failure is responsive to cardioversion to normal sinus rhythm. It is unclear if the
WORLD NEUROSURGERY 114: 348-351, JUNE 2018
Conflict of interest statement: The authors have no disclosures to report. Received 16 November 2017; accepted 9 March 2018 Citation: World Neurosurg. (2018) 114:348-351. https://doi.org/10.1016/j.wneu.2018.03.071 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
351