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J M Gilsbach

Publications and source records attributed to J M Gilsbach.

At least 19 recordsLinked to original sources
PubMed2007

Combined motor and somatosensory evoked potentials for intraoperative monitoring: intra- and postoperative data in a series of 69 operations.

The primary objective of neurophysiologic monitoring during surgery is to avoid permanent neurological injury resulting from surgical manipulation. To prevent motor deficits, either somatosensory (SSEP) or transcranial motor evoked potentials (MEP) are applied. This prospective study was conducted to evaluate if the combined use of SSEP and MEP might be beneficial. Combined SSEP/MEP monitoring was attempted in 100 consecutive procedures, including intracranial and spinal operations. Repetitive transcranial electric motor cortex stimulation was used to elicit MEP from muscles of the upper and lower limb. Stimulation of the tibial and median nerves was performed to record SSEP. Critical SSEP/MEP changes were defined as decreases in amplitude of more than 50% or increases in latency of more than 10% of baseline values. The operation was paused or the surgical strategy was modified in every case of SSEP/MEP changes. Combined SSEP/MEP monitoring was possible in 69 out of 100 operations. In 49 of the 69 operations (71%), SSEP/ MEP were stable, and the patients remained neurologically intact. Critical SSEP/ MEP changes were seen in six operations. Critical MEP changes with stable SSEP occurred in 12 operations. Overall, critical MEP changes were recorded in 18 operations (26%). In 12 of the 18 operations, MEP recovered to some extent after modification of the surgical strategy, and the patients either showed no (n = 10) or only a transient motor deficit (n = 2). In the remaining six operations, MEP did not recover and the patients either had a transient (n = 3) or a permanent (n = 3) motor deficit. Critical SSEP changes with stable MEP were observed in two operations; both patients did not show a new motor deficit. Our data again confirm that MEP monitoring is superior to SSEP monitoring in detecting impending impairment of the functional integrity of cerebral and spinal cord motor pathways during surgery. Detection of MEP changes and adjustment of the surgical strategy might allow to prevent irreversible pyramidal tract damage. Stable SSEP/MEP recordings reassure the surgeon that motor function is still intact and surgery can be continued safely. The combined SSEP/ MEP monitoring becomes advantageous, if one modality is not recordable.

Adolescent↗
PubMed2006

Electrophysiological proof of diffusion-weighted imaging-derived depiction of the deep-seated pyramidal tract in human.

In the living human brain the pyramidal tract (PT) can be displayed with magnetic resonance diffusion-weighted imaging (DWI). Although this imaging technique is already being used for planning and performing neurosurgical procedures in the PT vicinity, there is a lack of verification of DWI accuracy in other areas outside the directly subcortical PT parts. Before definitive electrode placement into the subthalamic nucleus (STN) in patients with Parkinson disease (PD) for chronic stimulation, the stimulation effect on PD symptoms and the side-effects, namely PT activation at the level of the internal capsule (IC), are electrophysiologically tested. To analyze DWI accuracy by matching the stereotactic coordinates of the electrophysiologically proven IC position with these of the DWI-derived IC display, DWI was added to the routine MRI work-up in the stereotactic frame prior to functional surgery in 6 patients. In all of the 10 displayed fiber tracts, concordant findings for imaging and macrostimulation were made. The authors proved for the first time that DWI correctly depicts the deep seated, principle motor pathways in the living human brain. Due to methodical limitations of this study the accuracy of the proven IC display is limited to 3 mm which has proven to be sufficient for the planning and performance of neurosurgical procedures in the vicinity of large fiber tracts.

Adult↗
PubMed2005

A rare but life-threatening complication of ventriculo-atrial shunt.

Insertion of ventriculoperitoneal and ventriculoatrial shunts is routinely performed. Infarction pneumonia and atrial thrombus formation are described as very rare complications of ventriculoatrial shunts. We present the case of a female patient with ventriculoatrial shunt insertion as long term treatment for aequeductal stenosis who presented with recurrent episodes of dyspnoea, chest pain, and unilateral pleural effusion. Diagnostic evaluation revealed a positive D-dimer test, bilateral basal infiltrates and pleural effusion. Transesophageal echocardiography established the diagnosis of a thrombus in the right atrium. Laboratory testing for thrombophilia revealed a homozygous factor V Leiden mutation. In the following, a shunt revision was performed.

Adult↗
PubMed2005

Technical pitfalls in a porcine brain retraction model. The impact of brain spatula on the retracted brain tissue in a porcine model: a feasibility study and its technical pitfalls.

We describe technical pitfalls of a porcine brain injury model for identifying primary and secondary pathological sequelae following brain retraction by brain spatula. In 16 anaesthetised male pigs, the right frontal brain was retracted in the interhemispheric fissure by a brain spatulum with varying pressures applied by the gravitational force of weights from 10 to 70 g for a duration of 30 min. The retracted brain tissue was monitored for changes in intracranial pressure and perfusion of the cortex using a Laser Doppler Perfusion Imager (MoorLDI). To evaluate the extent of oedema and cortical contusions, MRI was performed 30 min and 72 h after brain retraction. Following the MR scan, the retracted brain areas were histopathologically assessed using H&E and Fluoro-Jade B staining for neuronal damage. Sinus occlusion occurred in four animals, resulting in bilateral cortical contusions and extensive brain oedema. Retracting the brain with weights of 70 g (n = 4) caused extensive oedema on FLAIR images that correlated clinically with a hemiparesis in three animals. Morphologically, an increased number of Fluoro-Jade B-positive neurons were found. A sequential decrease in weights prevented functional deficits in animals. A retraction pressure applied by 10-g weights (n = 7) caused a mean rise in intracranial pressure to 4.0 +/- 3.1 mm Hg, and a decrement in mean cortical perfusion from 740.8 +/- 41.5 to 693.8 +/- 72.4 PU/cm2 (P < 0.24). A meticulous dissection of the interhemispheric fissure and a reduction of weights to 10 g were found to be mandatory to study the cortical impact caused by brain spatula reproducibly.

Analysis of Variance↗
PubMed2005

Diffusion-weighted imaging-guided resection of intracerebral lesions involving the optic radiation.

In this paper we report our experience with diffusion-weighted imaging (DWI) for optic radiation (OR) visualization during resection of tumors. We hypothesize that intraoperative OR visualization helps to maintain patients' visual fields. DWI studies were performed together with T1-weighted postcontrast magnetic resonance imaging (MRI) in four patients with lesions in or adjacent to the OR (glioblastoma, oligo-astrocytoma, cavernoma, and metastasis; n = 1 each). The OR was identified from one of six DWI data acquisitions, segmented and reconstructed three-dimensionally. The image data were neuronavigationally transferred into the operative field, and provided the neurosurgeon with information on lesion site and adjacent OR localization. Preoperative and postoperative neuroophthalmological testing included, among others, perimetry to define the value of diffusion-weighted image guidance during OR lesion resection. Three lesions were removed completely. In one case, low-grade tumor parts infiltrating the OR were intentionally left. No persistent visual field deficits were induced. In one patient, a transient homonymous hemianopia attributable to postoperative swelling completely resolved under steroid medication. The authors conclude that intraoperative OR visualization, realized by neuronavigationally displayed DWI data, might prove to be helpful to maintain patients' visual fields.

Affect↗
PubMed2005

Image-guided microneurosurgical management of small cerebral arteriovenous malformations: the value of navigated computed tomographic angiography.

In small arteriovenous malformations (AVM) with large hematomas, surgery remains the main therapeutic option. However, intraoperative identification of the AVM, feeders, and draining veins could be difficult in the environment of substantial intracerebral blood. In those selected cases, we use navigated computed tomographic angiography (CTA) for the microneurosurgical management. It is our objective to report our initial experiences. Prior to operation a conventional CTA with superficial skin fiducials placed on a patient's head was acquired for diagnostic and neuronavigation purposes. Image data were transferred to a neuronavigation device with integrated volume rendering capacities which allows a three-dimensional reconstruction of the vascular tree and the AVM to be created. In all patients the AVM was removed successfully after having been localized with CTA-based neuronavigation. Navigated CTA is helpful for the operative management of small AVMs with large hematomas. The technique allows feeding arteries to be distinguished from draining veins thereby allowing the nidus of the AVM to be identified despite the presence of substantial intracerebral blood. CTA can be easily implemented into commercial neuronavigation systems.

Adult↗
PubMed2005

Advanced neuronavigation in skull base tumors and vascular lesions.

OBJECTIVE: The purpose of this study was to describe the usefulness of recent advances of neuronavigational technology in the management of skull base tumors and of vascular lesions, treated via a skull base approach. METHODS: In 16 patients (skull base meningioma n = 9, petrous apex epidermoid n = l, craniopharyngeoma n = 1, giant internal carotid artery aneurysm n = 1, basilar/vertebral artery aneurysm n = 2, brain stem cavernoma n = 2), "advanced" neuronavigation was used. In contrast to "conventional" neuronavigation, the information for the neurosurgeon was enhanced by the intraoperative screen display of 3-dimensional reconstructions of the lesion, vessels, nerves and fiber tracts at risk. The 3-dimensional reconstructions were obtained by preoperative manual or automated segmentation processes. In addition, different imaging modalities (computed tomography [CT] with magnetic resonance imaging [MRI], CT with CT angiography, T (l)- with diffusion-weighted MRI) were fused and shown on the screen. RESULTS: In the cases of tumors, "advanced" neuronavigation facilitated the approach (n = 4), contributed to tailor the approach (n = 2) and helped to identify hidden neurovascular structures (n = 9). In the cases of aneurysms, "advanced" neuronavigation allowed us to reduce the skull base approach to the needs of safe aneurysm clipping (n = 3). In both cases of brain stem cavernoma, "advanced" neuronavigation was deemed useful for definition of the best surgical approach in relation to the pyramidal tract and brain stem nuclei. CONCLUSION: The authors' experiences suggest that neuronavigation, which displays 3-dimensional reconstructions of lesion, vessels, nerves and fiber tracts during surgery and makes use of image fusion techniques, is an important tool in the neurosurgical management of skull base lesions.

Adolescent↗
PubMed2005

Head injury after a fall on stairs: poorer prognosis in inebriated patients?

AIM: The aim of the present study was to determine whether inebriated patients falling on stairs sustain more severe head injuries than sober patients because of a delayed reaction time and a pathological coagulation and clotting system. PATIENTS AND METHODS: The files of 140 head-injured patients who came to admission after falling on stairs were retrospectively reviewed with respect to demographic data, initial Glasgow coma scale (GCS) score, type of hematoma, coagulation parameters and outcome (death versus survival, Glasgow Outcome Scale [GOS] score GOS 3-5 vs. GOS 1 and 2). RESULTS: There were 69 patients who had an alcohol level of > or = 0.8 parts per thousand at the time of the fall (49.0 %). The mortality in the group of inebriated patients was 12.9 %, in the group of sober patients 33.3 % (p = 0.001). The characteristics of the two groups were comparable, except for age (50.4 vs. 69.1 years, p = 0.001). The analysis of mortality in relation to age confirmed the finding of a lower mortality rate in inebriated patients. CONCLUSION: The hypothesis that inebriated patients sustain more severe head injuries with higher mortality rates could not be validated. Routine laboratory tests did not detect coagulation and clotting disorders in inebriated patients. Instead, our study again showed that age is one of the major prognostic factors in head injury.

Aged↗
PubMed2005

Motor evoked potentials following highly frequent transcranial magnetoelectrical motor cortex stimulation: normal data and potential modulation by stimulation-dependent inhibitory and activating mechanisms.

OBJECTIVE: To determine the normal values (latency, amplitude) of motor evoked potentials (MEP) of the abductor pollicis brevis (APB) and tibialis anterior (TA) muscle after high-frequency repetitive transcranial magnetic stimulation of the motor cortex (rTCMS), and to evaluate stimulation-dependent MEP modulations. PATIENTS AND METHODS: 29 healthy volunteers underwent rTCMS with 2 and 4 stimuli. The interstimulus interval (ISI) was 2, 3, and 4 ms respectively, which corresponded to frequencies between 250 and 500 stimuli/s. The evoked potentials of the relaxed and voluntarily contracted APB and TA were registered. RESULTS: Depending on the frequency and number of stimuli, the mean corticomuscular latency to the relaxed APB varied between 22.2 and 22.9 ms, and to the relaxed TA between 30.4 and 32.0 ms. The intra- and interindividual variability of the amplitudes was substantial. Voluntary contraction of the target muscle always led to a decrease in latency and increase in amplitude (p < 0.05). CONCLUSION: The high variability of the amplitudes does not allow the computation of meaningful normal values. The latencies after rTCMS are close to those of normal data after single TCMS, which indicates that in awake humans identical cortical and spinal structures are similarly activated. The discrete variations of latency and amplitude after changing the frequency and stimulus number suggest that inhibitory and excitatory mechanisms on the cortical and/or spinal level modulate the muscle response.

Adult↗
PubMed2005

Lateral transmuscular or combined interlaminar/paraisthmic approach to lateral lumbar disc herniation? A comparative clinical series of 48 patients.

BACKGROUND: The optimum operative technique for lateral lumbar disc herniations (LLDH) remains unclear, and both interlaminar and extraspinal approaches are used. OBJECTIVE: To compare outcome after LLDH removal either by a lateral transmuscular approach (LTM) or by a combined interlaminar and paraisthmic approach (CIP). METHODS: 28 patients underwent surgery using CIP and 20 using LTM. All patients were operated on by the same neurosurgeon. The clinical presentation of the two groups was comparable. Overall outcome was assessed after a mean follow up period of between 19 and 37 months using the Ebeling classification. In addition, the effect of surgery on radicular pain, low back pain, and sensory and motor deficits was defined. RESULTS: Excellent to good results were achieved in 95% of the LTM group and 57% of the CIP group. The outcome was satisfactory to poor in 5% of the LTM and 43% of the CIP group (p<0.004). The percentage of sensorimotor deficit and of radicular pain improvement was higher in the LTM group. New low back pain was found exclusively in the CIP group (21%). The complication rate was 5% in the LTM group and 11% in the CIP group. CONCLUSIONS: The LTM approach achieves a better overall outcome and improvement in radiculopathy. The complication rate is lower with the transmuscular route and the risk of new low back pain is minimised. These results are likely to be attributable at least in part to the lesser invasiveness of the LTM approach.

Diskectomy↗
PubMed2004

Haemorrhagic tracheal necrosis as a lethal complication of an aneurysm model in rabbits via endoluminal incubation with elastase.

BACKGROUND: We describe a lethal complication of an aneurysm model in rabbits for saccular aneurysmal creation via endoluminal incubation with elastase. METHOD: In 24 anaesthetized female New Zealand White rabbits, the right common carotid artery (CCA) was ligated distally to the arteriotomy. A 4F sheath was then placed retrograde into the CCA, and its origin was occluded endoluminally using a 2F Fogarty balloon. Elastase was incubated above the balloon in the separated vessel lumen for the duration of 20 minutes. Two weeks later, digital subtraction angiography was performed for aneurysm control. Two animals were then sacrificed and the aneurysm studied on histology. All animals that died within the experiment were examined post-mortem. FINDINGS: Following this protocol, an aneurysm with a mean size of 7.6 x 3.2 mm could be created in 11 out of 24 animals. 9 out of 13 animals with lethal outcome died from haemorrhagic necrosis of the trachea with subsequent pulmonary complications. DSA releaved an arterial branch originating from the proximal CCA in a near 90 degree-angle aiming at the trachea. INTERPRETATION: The endoluminal incubation with elastase is suitable for aneurysm creation of reproducible size that are suited to test new endovascular devices such as stents and new coils. One should always be aware of an arterial branch of the CCA supplying the trachea. In case of elastase instillation into this branch, lethal haemorrhagic necrosis of the trachea occurs. Bearing this complication in mind, we have experienced a minimal loss of animals in subsequent studies.

Animals↗
PubMed2004

Course of brain shift during microsurgical resection of supratentorial cerebral lesions: limits of conventional neuronavigation.

BACKGROUND: The authors have conducted a prospective study to evaluate the amount and course of brain shift during microsurgical removal of supratentorial cerebral lesions, and to assess factors which potentially influence these shifts. METHOD: In 61 patients the displacement of 2-3 cortical landmarks on the cerebral surface was dynamically quantified during surgery, i.e. during dissection of the tumour at the estimated half-time of surgery, and at the end of microsurgical removal of the cerebral lesion using the neuronavigation system EasyGuide Neuro. In 14 of these patients the displacement of a subcortical landmark was additionally analysed. Age of the patients, preoperative midline shift, location of the lesion, lesion volume, depth of the lesion below the cortical surface, presence or absence of oedema, and size of the craniotomy were analysed for potential influence on the amount of brain shift. Correlations were analysed for all patients together and for the subgroups of vault meningiomas (n=10), gliomas (n=30), and nonglial intra-axial lesions (n=21). FINDINGS: The mean displacement of the cortical landmarks ranged between 0.8 and 14.3 mm (mean: 6.1 mm, standard deviation: 3.4 mm) during surgery (10-210 minutes [mean: 50.7 minutes, standard deviation: 34.5 minutes] after dura opening) and between 2.4 and 15.2 mm (mean: 6.6 mm, standard deviation: 3.2 mm) at the end of microsurgical removal of the tumourous cerebral lesions (20-375 minutes [mean: 107.2 minutes, standard deviation: 65.6 minutes] after dura opening). Significant correlations (p<0.01) for the entire patient group were found between brain shift and tumour volume, midline shift, and size of the craniotomy, respectively. For the subgroup of vault meningiomas a significant correlation (p<0.01) between brain shift and patient age was found. For the subgroup of gliomas a significant correlation (p<0.01) between brain shift and tumour volume, midline shift and size of the craniotomy, respectively, was found. For the subgroup of nonglial intra-axial lesions a significant correlation (p<0.01) between brain shift and midline shift and between brain shift and size of the craniotomy was found. The quantity of shared common variance ranged between 10-50%. Performing a discriminant analysis, lesion volume was the only certain factor influencing brain shift intra-operatively as well as at the end of lesion removal. 58.5% of the extent of brain shift could be correctly classified by the tumour volume as the only discriminating variable during dissection of the tumour and at the end of surgery. Comparing superficial with subcortical brain shift over the same time period, a mean superficial shift of 4.6 mm (1.6-10.8 mm, standard deviation: 2.8 mm) and a mean subcortical shift of 3.5 mm (1.0-7.7 mm, standard deviation: 2.3 mm) was found. A highly significant Spearman correlation (Rho:.97, p<0.001) between superficial and subcortical brain shift emerged. Shifting of superficial landmarks exceeded shifting of subcortical structures in all patients. CONCLUSIONS: The data demonstrate the dynamics of brain shift and the limits of conventional neuronavigation and add additional support for the unavoidable inaccuracy of contemporary neuronavigational systems once the cranium is opened. Brain shift leads to a significant loss of reliability of neuronavigation systems during microsurgical removal of intracranial lesions and there are differences of the course and the amount of brain shift in relation to special subgroups of supratentorial cerebral lesions. However, because of the heterogeneous nature of lesions neurosurgeons have to remove, the modest quantity of shared common variance, and the differences between superficial and subcortical brain shift, it seems unlikely that the amount and course of brain shift become exactly predictable pre-operatively. Only an intra-operative update of image data should have the capacity to overcome this fundamental problem of modern neuronavigation.

Adolescent↗
PubMed2004

Functional and diffusion-weighted magnetic resonance imaging for visualization of the postthalamic visual fiber tracts and the visual cortex.

Diffusion-weighted magnetic resonance imaging (MRI) offers the possibility to study the course of the cerebral white matter tracts whereas functional MRI (fMRI) provides information about the specific functions of cortical areas. We evaluated the combination of fMRI and diffusion-weighted MRI to detect cortical visual areas with their corresponding visual fiber tracts in 15 healthy controls (age: 23 - 53 years, male : female = 8 : 7). We demonstrated activation within the primary visual cortex and white matter bundles connecting the lateral geniculate body and the striate cortex in all subjects investigated. Additional activation could be appreciated in some subjects within the lateral geniculate bodies (n = 2) and the motion-sensitive area V5 (n = 3). The combination of diffusion-weighted and functional imaging allows visualization of the origin, direction and functionality of large white matter tracts. This will prove helpful for imaging structural connectivity within the brain during functional imaging. Moreover, this technique might provide important information for neurosurgical patients presenting with space-occupying lesions close to the cortical and subcortical visual system since this technique can -- in contrast to diffusion tensor imaging -- easily be adopted into a neuronavigation system and can be performed on all MR scanners capable of diffusion-weighted imaging without specific post-processing programs.

Adult↗
PubMed2003

MRI and intraoperative findings in cavernous haemangiomas of the spinal cord.

More sensitive imaging techniques, such as MRI, have led to an increase in the number of reported cases of spinal cord cavernous haemangioma (SCCH). Complete surgical resection has been performed with good outcomes. However, operative findings do not always confirm preoperative MRI as to the size and site (superficial or deep) of the lesion. We evaluated whether MRI can be used to predict whether or not SCCH reach the surface of the spinal cord, since this has an impact on surgical strategy. We reviewed the preoperative MRI, case-notes and video recordings of 12 patients who underwent surgery, at which five superficial and seven deep-seated lesions were identified. T1-weighted images correctly indicated the site of the lesion in ten, T2-weighted images in only eight. One deep lesion was thought to be superficial on both T1- and T2-weighted images. Intravenous contrast medium was not helpful in diagnosis or localisation. In no case was a surgically proven superficial lesion interpreted as deep in the spinal cord.

Adult↗
PubMed2003

Endovascular treatment of experimentally induced aneurysms in rabbits using stents: a feasibility study.

Although Guglielmi detachable coil (GDC) systems have been generally accepted for treatment of intracranial aneurysms, primary stenting of aneurysms using porous stents or implantation of coils after stent placement remains experimental. Testing of these new methods requires an animal model which imitates human aneurysms in size, configuration and neck morphology. We assessed in detail the technical requirements of and steps for transfemoral stent treatment of experimentally induced aneurysms at the top of the brachiocephalic trunk in rabbits. We created aneurysms in ten rabbits by distal ligation and intraluminal digestion of the right common carotid artery with elastase. We treated five animals with porous stents alone, and five with stents plus coiling via the meshes of the stent, which permitted dense packing of coils. No complications related to the procedures occurred. In all animals, even in those treated solely with porous stents, total occlusion of the aneurysm was achieved. Our animal model can be suitable for testing the biocompatibility and occlusion rate of new methods and devices for the treatment of experimental aneurysms.

Aneurysm↗
PubMed2003

Extended pterional orbital decompression in severe orbital cellulitis.

BACKGROUND: Bacterial orbital cellulitis is a relatively uncommon infective process, which can threaten the function of orbital structures. Apart from antibiotic therapy, sinus surgery with or without abscess drainage via an orbito-otorhinolaryngological approach might be necessary. CASE DESCRIPTION: We present three cases of severe orbital cellulitis, leading to increasing loss of vision, proptosis, afferent pupillary disturbances and restriction of extra-ocular movements, despite antibiotic therapy. After extended pterional orbital decompression and reducing the orbital pressure by removal of the lateral and superolateral orbital walls, all patients showed distinct improvement of initial symptoms, without any complications related to the operation. INTERPRETATION: Extended pterional orbital decompression represents an effective treatment alternative and supplement in cases of a severe, threat to ocular function due to orbital cellulitis, where acute reduction of pressure on orbital, neural and vascular structures is intended.

Adult↗
PubMed2003

Experience with a new concept to lower non-infectious complications in infants with programmable shunts.

In neonates and infants less than 1 year of age who are treated with a ventriculo-peritoneal shunt, non-infectious complications are almost as frequent and dangerous as infectious complications. While the incidence of infections can be reduced, using perioperative antibiotics, special surgical techniques and postoperative care non-infectious complications such as wound break-down, cerebrospinal fluid (CSF) fistula and subcutaneous CSF collection are preventable, but seem difficult to manage, especially in the group of patients at a susceptible age. The authors present their experience with the programmable Hakim valve in 40 neonates and infants less than 1 year of age, who were treated with de novo implantation of a ventriculo-peritoneal shunt due to various pathologies. The uneventful wound healing during the first weeks after shunt implantation, avoiding the above mentioned non-infectious complications, was supported by initial, temporary overdrainage and readjustment of the programmable valve after completed wound healing. All patients tolerated this procedure well and showed no pathological signs or symptoms of overdrainage like premature closure of cranial sutures, clinical low-pressure syndrome, slit ventricle syndrome (SVS), subdural fluid collection or brain collapse during an average follow-up period of 2.6 years (2 - 65 months). Infectious and other mechanical, non-infectious complications were analysed as well during the follow-up period. These results suggest that an initial, temporary overdrainage in infants and neonates with shunted hydrocephalus may contribute to further lower the incidence of non-infectious complications like wound break-down, CSF-fistula or subcutaneous CSF accumulation, without negative side effects. This technique could be a valuable option in the regimen of shunt-treatment of this age group in order to optimise the overall success rate and lower the general complication rate.

Female↗