A pictorial essay on approaches and potential pitfalls
  • N. Hammer
  • D. Häske
  • A. Höch
  • C. Babian
  • B. Hossfeld
  • P. Voigt
  • D. Winkler
  • M. Bernhard



Thoracic trauma with consecutive pneumothorax or haematothorax can be accompanied by progressive respiratory failure. If untreated, this poses the risk of developing a life-threatening tension pneumothorax and consecutive death. Needle decompression and thoracostomy with/without chest tube insertion are therefore considered being among the final life-saving measures.


The aim of the given work is to present the anatomical background of thoracostomy and needle decompression, and to provide an image-based compilation of the procedure and potential pitfalls, based on the new German level 3 guideline for the management of severely injured patients.

Materials and methods

Literature review, clinical intervention in cadaveric specimens, subsequent dissection and imaging.

Results and conclusions

Chest tube insertions are a suitable and effective but technically challenging procedure to treat a pneumothorax or haematothorax. Needle decompression is a simple but temporary procedure and is not considered as a measure for definite care. In the given work, the two most commonly used techniques for thoracostomy for chest tube insertion or needle decompression, namely Monaldi and Bülau, are demonstrated using radiological images, anatomical preparations and graphical illustrations. This guide illustrates thoracic and abdominal surface anatomy and shows the corresponding internal topography according to different levels, as well as the consequences of potential misplacements.


Chest tubes Hematothorax Needle decompression Respiratory failure Tension pneumothorax 


Bebilderte Anleitung zur Anlage und potenzielle Fehlerquellen



Das Thoraxtrauma mit konsekutivem Pneumothorax oder Hämatothorax geht neben einem möglichen respiratorischen Versagen mit dem Risiko einher, einen lebensbedrohlichen Spannungspneumothorax zu entwickeln, der unbehandelt zum Tod führen kann. Die Nadeldekompression und Thorakotomie mit/ohne Anlage einer Thoraxdrainage gehören zu den endgültigen bzw. lebensrettenden Maßnahmen.


Ziel der Arbeit ist es, die anatomischen und klinischen Hintergründe zur Thorakotomie und Dekompression darzustellen und eine bildgestützte Zusammenstellung der Vorgehensweise und möglicher Fallstricke aufzuzeigen. Die Beschreibung und Darstellung berücksichtigt auch die aktuelle Version der deutschen S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“.

Material und Methoden

Literatur- und Bildauswahl, Darstellung der klinischen Intervention an Körperspendern der Anatomie.

Ergebnisse und Diskussion

Die Anlage der Thoraxdrainage ist eine geeignete und wirksame, aber technisch schwierige und daher komplikationsbehaftete Maßnahme. Die Nadeldekompression ist eine einfache, aber nur vorübergehende Maßnahme und stellt keine definitive Versorgungsoption dar. Diese Arbeit zeigt die beiden am häufigsten verwendeten Techniken (Monaldi- und Bülau-Drainage) zur Thorakotomie bei Anlage der Thoraxdrainage oder Nadeldekompression anhand von radiologischer Bildgebung, anatomischen Präparaten und Grafiken. Die Anleitung weist auf mögliche Fehlanlagen und die Zuordnung der entsprechenden Oberflächenanatomie zur inneren Thorax- und Abdominaltopographie hin.


Hämatothorax Nadeldekompression Respiratorisches Versagen Spannungspneumothorax Thoraxdrainage 


Thoracic trauma is the second most common traumatic cause of death [42, 43]. About 20% of all major blunt trauma cases are accompanied by a pneumothorax [26], underlining the need for out-of-hospital or in-hospital pleural decompression [32]. Both needle decompression [2] and thoracostomy followed by chest tube drainage [11, 32] may well serve to prevent injury-related complications rather than causing iatrogenic damage. However, complication rates largely depend on applying the correct and suitable technique [9, 12, 17, 36]. Also, though technical complications may not always hamper the effectiveness of thoracotomy or cause persistent harm [36], one should be aware of potentially life-threatening conditions following an inadequate insertion technique. A number of complications have been described in the literature, ranging between 3 and 37% [4, 13, 18, 26, 36, 38, 40, 44]. Recently, Kaserer et al. [29] presented a retrospective analysis over a 6-year period, in which 24 of 2261 trauma patients (1%) had undergone out-of-hospital chest decompression. A successful out-of-hospital release of a tension pneumothorax was reported in 83% of patients with tube thoracostomy, whereas needle thoracocentesis was only effective in 18%. According to these results, needle decompression is associated with failure rates higher than 80%. In line with the current German trauma guidelines, tube thoracostomies may already be considered in the out-of-hospital setting to retain sufficient pleural decompression upon admission. These results indicate that the technique of thoracostomy appears to be complex.

Consequently, the given pictorial guide aims at summarising the two most commonly used techniques (Bülau and Monaldi) for thoracostomy and needle decompression and to show potential pitfalls caused by common but preventable handling errors. For this purpose, both patient cases and clinical interventions in human cadavers were used to give an encompassing insight.


According to the German level 3 guideline for the management of severe injury, an evaluation of the chest and ventilation is recommended in patients suffering from chest trauma [3]. Herein is included the respiratory rate and auscultation of the chest followed by a consequent re-evaluation if needed. Moreover, inspection, palpation and percussion as well as the use of pulse oximetry should be carried out. Lung sonography has meanwhile evolved as a reliable diagnostic tool for the evaluation of a pneumothorax, thereby combining the low costs and the ease of use in the clinical environment [27, 47]. If the patient is mechanically ventilated, capnography and ventilation pressure monitoring should be used. Indicators of pneumothorax or tension pneumothorax may include but are not limited to decreased or missing unilateral respiratory sounds, cutaneous emphysema, serial rib fractures, upper venous congestion and high ventilation pressures [7, 8]. A suspected pneumo- or haematothorax should be kept in mind if the ventilation sounds are reduced unilaterally (always check the tube position, if the patient is intubated). A relevant pneumothorax is unlikely in the absence of auscultation pathologies, thoracic pain, or dyspnoea (Table 1; [48]). Moreover, it should be kept in mind that an undetected and initially small pneumothorax could develop into a life-threatening situation in the following clinical course, especially under ventilation.
Table 1

Clinical signs as indicators of pneumo- or haematothorax following blunt trauma. A one-sided diminished breath sound appears to be the most relevant sign. Adapted from [48]















(90% sensitivity, 98% specificity)

Thoracic pain





(57% sensitivity, 79% specificity)

Breath shortness





(43% sensitivity, 98% specificity)

A tension pneumothorax will be suspected under clinical circumstances with a unilateral loss of ventilation sound by auscultation, and a typical syndrome including severe respiratory and an obvious circulatory deterioration. One should keep in mind that an unrecognised tension pneumothorax is the most common reason for trauma-associated cardiac arrest. A tension pneumothorax consequently has to be treated already during the out-of-hospital emergency medical service (EMS) treatment interval. An assumed tension pneumothorax needs to be decompressed subsequently once observed. If a patient is intubated and ventilated (positive pressure ventilation), a pneumothorax noticed during auscultation should likewise be decompressed. A detected pneumothorax in a spontaneously breathing patient should be controlled and observed continuously.

Technical aspects and the method of decompression

A needle decompression of a tension pneumothorax should be done only one time, immediately followed by a surgical thoracostomy with or without the insertion of a chest tube. A pneumothorax without a tension component is commonly decompressed applying the thoracostomy technique if indicated. According to the recommendations of the German level 3 guideline for the management of severely injured patients [3], a thoracostomy should be performed using a digital insertion technique. Here the use of the trocars commonly supplied with the chest tubes should be strictly avoided [35, 40] to circumvent unintentional iatrogenic damage. Blunt widening of the intercostal space should be carried out with the finger tips. If the parietal pleura cannot be perforated digitally, closed scissors may be applied to reinforce the examining finger to facilitate this process, but with extreme care not to harm the lung parenchyma. A catheter sized 28–36 Fr is recommended in the case of traumatic haemato- or pneumothorax [19, 48] and an 8–14 Fr-sized catheter in the case of nontraumatic haemato- or pneumothorax [48].

Bülau drainage

The patient is positioned supine with the arm of the respective side abducted and using monitoring of the vital functions (e. g. ECG, blood pressure, pulse oximetry). The fourth to sixth ribs and respective intercostal spaces should be identified (Fig. 1a, b) before a potential entry point is identified cranially of the mammillary line in the middle or anterior axillary line (Fig. 1c). Placing a hand cranially into the patient’s axilla helps identifying the correct levels and is an easy way to prevent neurovascular pathways from being injured (Fig. 1c). Another approach is the so-called triangle of safety (Fig. 1d). The anterior border of the latissimus dorsi, the lateral border of the pectoralis major form this triangle of safety, and the internipple line, with one of the apices located the axillary fossa [22, 35].
Fig. 1

Bülau thoracostomy. In a (ventral view) and b (dorsal view) a cross-section in the anterior axillary line and spatial relations is shown; the asterix shows the site of the pneumothorax in b, and the dashed line the internipple line. In c and d (lateral view) two commonly used methods for excluding axillary fossa injury are summarised. The safe triangle method (c) uses the lateral margin of the pectoralis major, the anterior margin of the latissimus dorsi and an extension of the internipple line to delineate the region of thoracostomy (dashed figure). Alternatively, as shown in d, a hand is placed cranially in the axilla to cover the most vulnerable region of the axillary region. The solid line indicates the anterior axillary line, the dashed line the middle axillar line. In e (lateral view), the drainage is placed in the middle axillary line cranially in the fourth intercostal space, in f (dorsal view) in the anterior axillary line in the same intercostal space. 1–7 first to seventh rib, Cl clavicle. Courtesy of the authors

Fig. 1

Bülau thoracostomy. In g and h (both ventral view) it is shown how the index can be used to guide the drainage cranially or caudally in the fifth intercostal space, while il indicate the final tube placement following thoracostomy with the Bülau technique (i [lateral view] the drain is secured by a suture, j and k ventral view and l the corresponding dorsal view). 1–7 first to seventh rib, Cl clavicle. Courtesy of the authors. (Continued)

Following thorough disinfection and sterile draping, using sterile gloves, a sharp incision (2–4 cm) will be carried out by means of a scalpel, ideally in the fourth or fifth intercostal space in case of using the middle axillary line (Fig. 1e) or the fourth intercostal space in case of the anterior axillary line (Fig. 1f). Incisions 1 cm anterior of the middle axillary line appear to save neural structures such as the long thoracic nerve [9]. The incision should be extended manually by blunt preparation at the inferior rib of the respective intercostal space, pushing aside both intercostal muscles and the parietal pleura to access the pleural cavity. Furthermore, using the finger allows for palpation of the intercostal space. Danger of injury of the provider should be considered in case of bony fragments.

A finger can be used to guide the tip of the drainage either cranially (pneumothorax; Fig. 1g) or caudally (e. g. haematothorax, serothorax; Fig. 1h). In adults, a drainage insertion length of 15–20 cm may serve as a reference value but depends on the patients’ length ratio. Care should be taken that some manufacturers do not give the total length of the drainage rather than the distance to the most proximal drainage hole – for these types the maximum insertion distance given by the scale should be 5–10 cm less. Following the insertion, the drainage should be secured by 1.0 silk suturing (Fig. 1i) before the incision is covered by wound dressings. If applied, a Heimlich valve may be utilised to maintain suction pressures of 20–30 cm H2O [16, 35, 49]. However, if the Heimlich system is mounted incorrectly, this may even result in a deterioration of the pneumothorax [10]. Moreover, a vacuum of this extent may not be generated in the common out-of-hospital setting. Here, Heimlich systems may only help to decrease the air influx onto the pleural cavity. Therefore, the use of Heimlich systems during routine use may not be recommended. Two potential final positions of the drainage tip following thoracostomy according to the Bülau technique are depicted in Fig. 1j–l.

Monaldi drainage

The patient is positioned supine with the arm of the respective side adducted along the chest and using monitoring of the vital functions (e. g. ECG, blood pressure, pulse oximetry; Fig. 2a). The first and second rib and respective intercostal spaces should be identified before a potential entry point is identified in the medial clavicular line. To identify the second rib, it might be helpful to palpate the sternal angle between manubrium and corpus of the sternum. Following thorough disinfection and sterile draping, using sterile gloves, a sharp incision (2–4 cm) should be carried out by means of a scalpel, ideally in the second intercostal space (Fig. 2b). The incision should be extended manually by blunt digital preparation at the inferior rib of the respective intercostal space, pushing aside both intercostal muscles and the parietal pleura to access the pleural cavity. Furthermore, using the finger allows for palpation of the intercostal space and for placing the drainage. The danger of self-injury of the provider should be considered in case of bony fragments. Fig. 2c shows the drainage in a potential end position; 1.0 silk suturing should be done to secure the drainage (Fig. 2d).
Fig. 2

Monaldi thoracostomy, anterolateral view. a A finger is used to identify the first and second intercostal space in the midclavicular line (dashed line) before a skin incision is made (b). The trocar must not be used and should be removed before the drain is placed intrathoracic spreading the intercostal space with a finger (c). The drain should be secured with a suture (d). 1–7 first to seventh rib, Cl clavicle, dashed line internipple line. Courtesy of the authors


  1. 1.

    The use of scissors to expand the incision (Fig. 3a) may cause damage to the lung parenchyma (Fig. 3b). Manual digital techniques should be preferred.

  2. 2.

    Trocars offer a high risk of iatrogenic injury (Fig. 3c Monaldi, 3d Bülau), e. g. parenchymal damage of the lungs (Fig. 3e) or cardiac injury (Fig. 3f), and should therefore be avoided in any stage of thoracostomy and drainage [35, 40].

  3. 3.

    Placement caudal of the fifth intercostal space may result in diaphragmatic, hepatic, splenic and/or intestinal lesions (Fig. 3g). A sufficient identification of the insertion point is essential.

  4. 4.

    The posterior intercostal vessels and nerve usually run cranially in the intercostal space, merging with the two (anterior) intercostal branches for each segment originating from the internal thoracic artery, one running cranially and one caudally. The anastomosis of the posterior intercostal artery with the anterior intercostal branches is usually found in the middle or anterior axillary line, but can also be located more dorsally (Fig. 3h). This anatomical variation may then cause arterial bleeding if thoracostomy is carried out according to the existing guidelines. Moreover, hypertension-related coiling may cause displacement of the intercostal artery in the intercostal space (Fig. 3h).

  5. 5.

    Insertion technique should always respect the anatomy (Fig. 3i). Insertion should be applied on the upper part of the ribs (Fig. 3j) and using blunt digital technique (Fig. 3k).

Fig. 3

Pitfalls in thoracostomy. Using scissors for cutting tissues (a, lateral view) may likely result in parenchymal damage (b, ventral view). Trocar application (c, d, anterolateral and lateral view) may result in intralobar (e, ventral view) and cardiac injury (f, dorsal view). Courtesy of the authors

Fig. 3

Pitfalls in thoracostomy. Trocar application may also result in diaphragmatic, hepatic or gastrointestinal injury (g, ventral view). h (ventral view) shows the position of the intercostal vessels. Coiling of the intercostal arteries may cause arterial injury following thoracostomy even if the incision is made caudally in the intercostal space (h right). i (lateral view) shows the anatomy of the lateral thoracic wall, j (lateral view) the space where blunt dissection can take place, at best using the finger (k, lateral view). Solid line internipple line. IA intercostal artery, IV intercostal vein, IN intercostal nerve. Courtesy of the authors. (Continued)

Clinical imaging for positional control

In the case of a tension pneumothorax, a correctly positioned and effective pleural decompression is an important clinical issue. Furthermore, both X‑ray imaging and computed tomography (CT) can be used for positional control of thoracic drainage. Interlobar or intrapulmonary drainage displacement have to be considered if a persistent pneumothorax is seen on chest X‑ray images despite chest tube application (Fig. 4a). The reliable differentiation of the chest tube position within the lung parenchyma or along the interlobar fissure is difficult on the basis of plain X‑ray. In contrast, the diagnosis of an interlobar chest tube position in CT is facilitated when the lobar borders are clearly distended by the chest tube and a subsequent air filled pleural triangle is seen at the entry of the drainage to the interlobar fissure near the chest wall (Fig. 4b, c). However, even in CT the evaluation of an extra- or intrapulmonary position can sometimes be hampered if the interlobar chest tube is constricted and embedded from the interlobar fissure to the adjacent lung tissue. Generally an intrapulmonary chest tube placement can be assumed when the tube is surrounded by alveolar haemorrhages (Fig. 4d, e). As one may observe haemorrhages adjacent to constricted interlobar chest tubes in some cases, they can be discriminated easily from simple dystelectasis. Again, this is a domain of CT imaging where alveolar haemorrhages can be diagnosed, based on the observation of diffuse ground glass opacities. Fig. 4f shows an epicardial chest drain placement, caused by inadequate trocar use.
Fig. 4

Radiological evaluation of chest drains. In a (anterior view) an X‑ray with correct tube placement on the right side and a subcutaneous tube placement on the left side is shown. In b (transverse) and c (axial) the chest drain is placed inter lobar as seen in computed tomography, de (transverse) confirm the suspected diagnosis of intrapulmonal placement with surrounding haemorrhage. In f (transverse), an epicardial placement is seen in computed tomography. Courtesy of the authors

Needle decompression

Needle decompression may be indicated in case of a tension pneumothorax. Vice versa, no contraindications exist for a suspected tension pneumothorax. A large needle diameter (12 G or 14 G) should be selected according to the German level 3 guideline [3]. The approach of choice is the second or third intercostal space in the midclavicular line (Monaldi position; Fig. 5a–c), or the fourth to fifth intercostal space in the midaxillary or anterior axillary line (Bülau position; Fig. 5d, e). Some authors recommend the latter position, as the thickness of the chest wall is significantly larger in this region, making needle decompression more likely to be successful. Longer needles were also discussed, which is often based on results in computer tomography studies [14, 25]. In military setting, 8 cm long needles are used already, currently recommended by Prehospital Trauma Life Support (PHTLS) [41] and Advanced Trauma Life Support (ATLS) [45]. The recently-published German level 3 guideline of management of severely injured patients does to date not recommend a puncture site, or a needle length. It should be kept in mind that especially in the latter position (Bülau position), even with needle lengths of 4.5–5 cm or >8 cm, the risk persists for an injury of relevant intrathoracic organs (e. g. the ventricles).
Fig. 5

Needle thoracostomy. The second intercostal space is identified in the middle clavicular line (a, dashed line, anterolateral view) before a needle is inserted (b, anterolateral view). In c (dorsal view) the needle placement in the anterior thoracic wall is shown. Needle thoracostomy can alternatively also be carried out in the Bülau position (dashed line middle axillary line, solid line extension of the internipple line) as shown in d and e (both lateral view), respectively. 1–5 first to fifth rib, Cl clavicle. Courtesy of the authors


The primary aim of this study was to summarise the two most commonly used techniques applied for thoracostomy on the basis of both patient cases and clinical interventions shown in cadaveric tissues. Furthermore, this guide aimed at showing actual visual and spatial insights into potential malpositioning and to figure the corresponding surface anatomy levels to internal thoracic and abdominal topography. There is published evidence on the complication rates following thoracic drainage, ranging between 7 and 26% [4, 5, 13, 16, 18, 26, 36, 38, 40, 44]. Technical complications including malpositioning account for approximately one third of these cases (Table 2).
Table 2

Complication rates following chest tube insertion resulted from studies. Approximately one third of all patients were treated with more than one chest tube. Complications ranged between 7 and 26% with a clear increase since 1995


Complication rates (in %)

Patients with drains


Complications (absolute)

Bailey et al. (2000) [11]





Baldt et al. (1995) [28]




Chan et al. (1997) [12]




Daly et al. (1985) [24]




Etoch et al. (1995) [13]




Huber-Wagner et al. (2007) [3]





Maybauer et al. (2012) [10]




Menger et al. (2012) [14]




Millican et al. (1980) [15]




Sethuruman et al. (2008) [16]




Complications following thoracostomy are mostly related to the injury severity [35, 38] and the presence of extrathoracic injury [38] with no difference between the Bülau and the Monaldi techniques [38], though the complications are closely related to the respective anatomical site [35]. Chest drains are more likely to be applied in air rescue settings than in ground-based emergency settings [32, 31], which has implications on injury severity. None of the two positions appears superior with regard of patient outcomes [26]. Chest tube malfunction appears to be an unreliable indicator of incorrect chest tube position [5]. In cases of suspected malpositioning CT may be useful reduce patients’ morbidity, but also help distinguishing fissural from parenchymal lung placement [5, 12]. In these cases, CT is superior to standard X‑ray [5]. Interlobar or intrapulmonary chest tube displacement should be considered in any case of persistent pneumothorax. Using CT, alveolar haemorrhages surrounding the chest tube clearly indicate an intrapulmonary chest tube position.

A number of potential malpositioning sites have been described, such as
  • subcutaneous placement ([6, 7, 8, 13, 26, 36]; Fig. 4a, left patient side),

  • intrapulmonary (parenchymal) placement ([11, 26, 40]; Fig. 4d, e),

  • diaphragmatic, hepatic or intestinal injury [7, 8, 28, 39, 44],

  • vessel obstruction or laceration including the internal thoracic artery, pulmonary vessels and the aorta [15, 20, 44, 46],

  • tracheal or oesophageal obstruction or injury [12],

  • cardiac or pericardial compression or injury ([1, 12, 23, 30, 33, 34, 37]; Fig. 4f),

  • nerve injury, e. g. Horner’s syndrome or long thoracic nerve damage [9, 24].

Though both vascular and cardiac injury appear to be extremely rare, these entities often terminate lethal if precautions are not taken seriously [15, 22].

Bowness et al. [9] found that according to the guidelines of the European Trauma Course, British Thoracic Society and the ATLS, the sixth intercostal space or below are being used in more than 80% of all cases, which increases the risk of subdiaphragmatic injury. Similar findings were reported by Griffith et al. [21]. For this reason, the fifth intercostal space should be the lowest insertion point for the Bülau technique to minimise the risk of diaphragmatic or abdominal injury.


Thoracic trauma with consecutive pneumothorax or haematothorax is often accompanied by respiratory failure and the risk of developing a life-threatening tension pneumothorax, leading to death if untreated due to a decrease in cardiac output (including decreased blood pressure) as a consequence of mediastinal shift and the compression of the aorta and vena cava. Needle decompression and thoracostomy or chest tubes are accompanied to the final respectively life-saving measures. Therefore, a thorough clinical examination of the thoracic and respiratory function should be carried out. The suspected diagnosis of pneumo- and/or haematothorax is to be made with a weakened or missing respiratory sound by auscultation, chest pain and dyspnoea. A tension pneumothorax is possible with a unilateral lack of ventilation sounds in auscultation and severe respiratory or circulatory dysfunction. A clinically suspected tension pneumothorax is to be decompressed immediately applying the needle decompression technique followed by a surgical thoracostomy with or without the insertion of a chest tube, and likewise, thoracostomy can also be carried out primarily.

The Bülau position is between the fourth and sixth rib, cranially of the mammillary line in the middle or anterior axillary line. A second landmark for this position is the so-called triangle of safety. The Monaldi position is between the first and second rib and the medial clavicular line. The most common pitfalls include a too short cannula for needle decompression, the use of scissors to expand the incision or the use of a trocar, causing damage to the lung parenchyma, as well as an incorrect position for incision.



The authors express their gratitude to the body donors for donating their corpses for teaching and research projects after passing away. The authors also thank their families for supporting their valuable decision. We also thank Matthias Oehme and Thomas Wolfskämpf with the prosections. Christine Auste took the images and Robbie McPhee draw the illustrations forming an integral part of this pictorial essay.

Compliance with ethical guidelines

Conflict of interest

N. Hammer, D. Häske, A. Höch, C. Babian, B. Hossfeld, P. Voigt, D. Winkler and M. Bernhard declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.


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Copyright information

© Springer Medizin Verlag GmbH 2017

Authors and Affiliations

  • N. Hammer
    • 1
    • 2
  • D. Häske
    • 3
  • A. Höch
    • 4
  • C. Babian
    • 5
  • B. Hossfeld
    • 6
  • P. Voigt
    • 7
  • D. Winkler
    • 8
  • M. Bernhard
    • 9
  1. 1.Department of AnatomyUniversity of OtagoDunedinNew Zealand
  2. 2.Institute of AnatomyUniversity of LeipzigLeipzigGermany
  3. 3.Faculty of MedicineEberhard Karls University TübingenTübingenGermany
  4. 4.Department of Orthopaedics, Trauma and Reconstructive SurgeryUniversity Clinic of LeipzigLeipzigGermany
  5. 5.Institute of Forensic MedicineUniversity of LeipzigLeipzigGermany
  6. 6.Department of Anesthesiology and Intensive Care Medicine, Section Emergency MedicineFederal Armed Forces Medical HospitalUlmGermany
  7. 7.Division of NeuroradiologyUniversity Clinic of LeipzigLeipzigGermany
  8. 8.Department of NeurosurgeryUniversity Clinic of LeipzigLeipzigGermany
  9. 9.Emergency DepartmentUniversity Hospital of LeipzigLeipzigGermany

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