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Management of Patient with Motor Strip Gliomas (Awake Craniotomy)

  • L. Jane EasdownEmail author
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Abstract

Awake craniotomy is performed for resection of lesions in the eloquent areas of the brain. This operation is common to most academic medical centers. Key to the success of awake craniotomy is patient selection and preoperative preparation. The intraoperative management includes the choice of sedation throughout the procedure or general anesthesia at key times. Regional scalp blocks or local infiltration are used for analgesia. The advantage of the awake craniotomy is having the patient assist in mapping the language/motor or sensory centers to maximize resection yet protecting these areas. This is accomplished with intraoperative cortical stimulation while accomplishing speech or motor tasks. Patients have a high satisfaction with awake craniotomy although some identify pain and anxiety during the procedure. Awake craniotomy can decrease costs, hospital stay and even be managed as outpatient surgery.

Keywords

Awake craniotomy Language mapping Regional scalp blocks Intracranial tumor Aphasia Functional MRI 

References

  1. 1.
    Meng L, McDonagh DL, Berger MS, Gelb AW. Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner. Can J Anaesth. 2017;64(5):517–29.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Dreier JD, Williams B, Mangar D, Camporesi EM. Patients selection for awake neurosurgery. HSR Proc Intensive Care Cardiovasc Anesth. 2009;1(4):19–27.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Garavaglia MM, Das S, Cusimano MD, Crescini C, Mazer CD, Hare GM, et al. Anesthetic approach to high-risk patients and prolonged awake craniotomy using dexmedetomidine and scalp block. J Neurosurg Anesthesiol. 2014;26(3):226–33.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Hervey-Jumper SL, Li J, Lau D, Molinaro AM, Perry DW, Meng L, et al. Awake craniotomy to maximize glioma resection: methods and technical nuances over a 27-year period. J Neurosurg. 2015;123(2):325–39.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Meng L, Han SJ, Rollins MD, Gelb AW, Chang EF. Awake brain tumor resection during pregnancy: decision making and technical nuances. J Clin Neurosci. 2016;24:160–2.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Sheshadri V, Chandramouli BA. Pediatric awake craniotomy for seizure focus resection with dexmedetomidine sedation-a case report. J Clin Anesth. 2016;32:199–202.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Skucas AP, Artru AA. Anesthetic complications of awake craniotomies for epilepsy surgery. Anesth Analg. 2006;102(3):882–7.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Sivasankar C, Schlichter RA, Baranov D, Kofke WA. Awake craniotomy: a new airway approach. Anesth Analg. 2016;122(2):509–11.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, Cote CJ, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081–93; quiz 117–8.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Huncke T, Chan J, Doyle W, Kim J, Bekker A. The use of continuous positive airway pressure during an awake craniotomy in a patient with obstructive sleep apnea. J Clin Anesth. 2008;20(4):297–9.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Ladino LD, Rizvi S, Tellez-Zenteno JF. The montreal procedure: the legacy of the great wilder penfield. Epilepsy Behav. 2018;83:151–61.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Gerritsen JKW, Vietor CL, Rizopoulos D, Schouten JW, Klimek M, Dirven CMF, et al. Awake craniotomy versus craniotomy under general anesthesia without surgery adjuncts for supratentorial glioblastoma in eloquent areas: a retrospective matched case-control study. Acta Neurochir. 2019;161(2):307-315.Google Scholar
  13. 13.
    Spena G, Schucht P, Seidel K, Rutten GJ, Freyschlag CF, D’Agata F, et al. Brain tumors in eloquent areas: a European multicenter survey of intraoperative mapping techniques, intraoperative seizures occurrence, and antiepileptic drug prophylaxis. Neurosurg Rev. 2017;40(2):287–98.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Kulikov A, Lubnin A. Anesthesia for awake craniotomy. Curr Opin Anaesthesiol. 2018;31(5):506–10.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Sacko O, Lauwers-Cances V, Brauge D, Sesay M, Brenner A, Roux FE. Awake craniotomy vs surgery under general anesthesia for resection of supratentorial lesions. Neurosurgery. 2011;68(5):1192–8. discussion 8-9.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Rajan S, Cata JP, Nada E, Weil R, Pal R, Avitsian R. Asleep-awake-asleep craniotomy: a comparison with general anesthesia for resection of supratentorial tumors. J Clin Neurosci. 2013;20(8):1068–73.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Eseonu CI, Rincon-Torroella J, ReFaey K, Lee YM, Nangiana J, Vivas-Buitrago T, et al. Awake craniotomy vs craniotomy under general anesthesia for perirolandic gliomas: evaluating perioperative complications and extent of resection. Neurosurgery. 2017;81(3):481–9.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Gamble AJ, Schaffer SG, Nardi DJ, Chalif DJ, Katz J, Dehdashti AR. Awake craniotomy in arteriovenous malformation surgery: the usefulness of cortical and subcortical mapping of language function in selected patients. World Neurosurg. 2015;84(5):1394–401.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Zanello M, Wager M, Corns R, Capelle L, Mandonnet E, Fontaine D, et al. Resection of cavernous angioma located in eloquent areas using functional cortical and subcortical mapping under awake conditions. Outcomes in a 50-case multicentre series. Neuro-Chirurgie. 2017;63(3):219–26.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Passacantilli E, Anichini G, Cannizzaro D, Fusco F, Pedace F, Lenzi J, et al. Awake craniotomy for trapping a giant fusiform aneurysm of the middle cerebral artery. Surg Neurol Int. 2013;4:39.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Erickson KM, Cole DJ. Anesthetic considerations for awake craniotomy for epilepsy. Anesthesiol Clin. 2007;25(3):535–55. ixPubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Chua TH, See AAQ, Ang BT, King NKK. Awake craniotomy for resection of brain metastases: a systematic review. World Neurosurg. 2018;120:e1128–e35.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Tzourio N, Crivello F, Mellet E, Nkanga-Ngila B, Mazoyer B. Functional anatomy of dominance for speech comprehension in left handers vs right handers. NeuroImage. 1998;8(1):1–16.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Southwell DG, Hervey-Jumper SL, Perry DW, Berger MS. Intraoperative mapping during repeat awake craniotomy reveals the functional plasticity of adult cortex. J Neurosurg. 2016;124(5):1460–9.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Chang WH, Pei YC, Wei KC, Chao YP, Chen MH, Yeh HA, et al. Intraoperative linguistic performance during awake brain surgery predicts postoperative linguistic deficits. J Neuro-Oncol. 2018;139(1):215–23.CrossRefGoogle Scholar
  26. 26.
    Lim LH, Idris Z, Reza F, Wan Hassan WMN, Mukmin LA, Abdullah JM. Language mapping in awake surgery: report of two cases with review of language networks. Asian J Neurosurg. 2018;13(2):507–13.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Kim, Nadkarni TN, Andreoli MJ, Nair VA, Yin P, Young BM, et al. Usage of fMRI for pre-surgical planning in brain tumor and vascular lesion patients: task and statistical threshold effects on language lateralization. NeuroImage Clin. 2015;7:415–23.CrossRefGoogle Scholar
  28. 28.
    Kundu B, Penwarden A, Wood JM, Gallagher TA, Andreoli MJ, Voss J, et al. Association of functional magnetic resonance imaging indices with postoperative language outcomes in patients with primary brain tumors. Neurosurg Focus. 2013;34(4):E6.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Brown T, Shah AH, Bregy A, Shah NH, Thambuswamy M, Barbarite E, et al. Awake craniotomy for brain tumor resection: the rule rather than the exception? J Neurosurg Anesthesiol. 2013;25(3):240–7.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Eseonu CI, ReFaey K, Garcia O, John A, Quinones-Hinojosa A, Tripathi P. Awake craniotomy anesthesia: a comparison of the monitored anesthesia care and asleep-awake-asleep techniques. World Neurosurg. 2017;104:679–86.PubMedCrossRefGoogle Scholar
  31. 31.
    Kim SS, McCutcheon IE, Suki D, Weinberg JS, Sawaya R, Lang FF, et al. Awake craniotomy for brain tumors near eloquent cortex: correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients. Neurosurgery. 2009;64(5):836–45; discussion 345–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Yordanova YN, Moritz-Gasser S, Duffau H. Awake surgery for WHO grade II gliomas within “noneloquent” areas in the left dominant hemisphere: toward a “supratotal” resection. Clinical article. J Neurosurg. 2011;115(2):232–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Whiting BB, Lee BS, Mahadev V, Borghei-Razavi H, Ahuja S, Jia X, et al. Combined use of minimal access craniotomy, intraoperative magnetic resonance imaging, and awake functional mapping for the resection of gliomas in 61 patients. J Neurosurg 2019:1–9.Google Scholar
  34. 34.
    Maldaun MV, Khawja SN, Levine NB, Rao G, Lang FF, Weinberg JS, et al. Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases. J Neurosurg. 2014;121(4):810–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Hervey-Jumper SL, Berger MS. Technical nuances of awake brain tumor surgery and the role of maximum safe resection. J Neurosurg Sci. 2015;59(4):351–60.PubMedGoogle Scholar
  36. 36.
    Eseonu CI, Rincon-Torroella J, ReFaey K, Quinones-Hinojosa A. The cost of brain surgery: awake vs asleep craniotomy for perirolandic region tumors. Neurosurgery. 2017;81(2):307–14.PubMedCrossRefGoogle Scholar
  37. 37.
    Nassiri F, Li L, Badhiwala JH, Yeoh TY, Hachem LD, Moga R, et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors. J Clin Neurosci. 2019;59:162–6.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Howe KL, Zhou G, July J, Totimeh T, Dakurah T, Malomo AO, et al. Teaching and sustainably implementing awake craniotomy in resource-poor settings. World Neurosurg. 2013;80(6):e171–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Suero Molina E, Schipmann S, Mueller I, Wolfer J, Ewelt C, Maas M, et al. Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies in glioma surgery: an analysis of 180 patients. J Neurosurg. 2018;129(5):1223–30.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Stevanovic A, Rossaint R, Veldeman M, Bilotta F, Coburn M. Anaesthesia management for awake craniotomy: systematic review and meta-analysis. PLoS One. 2016;11(5):e0156448.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Meng L, Berger MS, Gelb AW. The potential benefits of awake craniotomy for brain tumor resection: an anesthesiologist’s perspective. J Neurosurg Anesthesiol. 2015;27(4):310–7.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Mack PF, Perrine K, Kobylarz E, Schwartz TH, Lien CA. Dexmedetomidine and neurocognitive testing in awake craniotomy. J Neurosurg Anesthesiol. 2004;16(1):20–5.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Souter MJ, Rozet I, Ojemann JG, Souter KJ, Holmes MD, Lee L, et al. Dexmedetomidine sedation during awake craniotomy for seizure resection: effects on electrocorticography. J Neurosurg Anesthesiol. 2007;19(1):38–44.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Bekker AY, Kaufman B, Samir H, Doyle W. The use of dexmedetomidine infusion for awake craniotomy. Anesth Analg. 2001;92(5):1251–3.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Osborn I, Sebeo J. “Scalp block” during craniotomy: a classic technique revisited. J Neurosurg Anesthesiol. 2010;22(3):187–94.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    McAuliffe N, Nicholson S, Rigamonti A, Hare GMT, Cusimano M, Garavaglia M, et al. Awake craniotomy using dexmedetomidine and scalp blocks: a retrospective cohort study. Can J Anaesth. 2018;65(10):1129–37.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Whittle IR, Midgley S, Georges H, Pringle AM, Taylor R. Patient perceptions of “awake” brain tumour surgery. Acta Neurochir. 2005;147(3):275–7; discussion 277.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Klimek M, van der Horst PH, Hoeks SE, Stolker RJ. Quality and quantity of memories in patients who undergo awake brain tumor resection. World Neurosurg. 2018;109:e258–e64.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Suess O, Picht T, Kuehn B, Mularski S, Brock M, Kombos T. Neuronavigation without rigid pin fixation of the head in left frontotemporal tumor surgery with intraoperative speech mapping. Neurosurgery. 2007;60(4 Suppl 2):330–8. discussion 8.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Pinsker MO, Nabavi A, Mehdorn HM. Neuronavigation and resection of lesions located in eloquent brain areas under local anesthesia and neuropsychological-neurophysiological monitoring. Minim Invasive Neurosurg. 2007;50(5):281–4.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Nathan N. Take it or leave it: a meta-analysis of perioperative ACE inhibitors and ARBs. Anesth Analg. 2018;127(3):589.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Bradic N, Povsic-Cevra Z. Surgery and discontinuation of angiotensin converting enzyme inhibitors: current perspectives. Curr Opin Anaesthesiol. 2018;31(1):50–4.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Walker SLM, Abbott TEF, Brown K, Pearse RM, Ackland GL. Perioperative management of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers: a survey of perioperative medicine practitioners. PeerJ. 2018;6:e5061.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Sitnikov AR, Grigoryan YA, Mishnyakova LP. Awake craniotomy without sedation in treatment of patients with lesional epilepsy. Surg Neurol Int. 2018;9:177.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Nossek E, Matot I, Shahar T, Barzilai O, Rapoport Y, Gonen T, et al. Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor. J Neurosurg. 2013;118(2):243–9.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Fontaine D, Almairac F. Pain during awake craniotomy for brain tumor resection. Incidence, causes, consequences and management. Neurochirurgie. 2017;63(3):204–7.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Wu PY, Huang ML, Lee WP, Wang C, Shih WM. Effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy. Complement Ther Med. 2017;32:56–60.PubMedCrossRefPubMedCentralGoogle Scholar
  58. 58.
    Frati A, Pesce A, Palmieri M, Iasanzaniro M, Familiari P, Angelini A, et al. Hypnosis-aided awake surgery for the management of intrinsic brain tumors versus standard awake-asleep-awake protocol: a preliminary, promising experience. World Neurosurg. 2019;121:e882–e91.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Zemmoura I, Fournier E, El-Hage W, Jolly V, Destrieux C, Velut S. Hypnosis for awake surgery of low-grade gliomas: description of the method and psychological assessment. Neurosurgery. 2016;78(1):53–61.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Manninen PH, Tan TK. Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth. 2002;14(4):279–83.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Bauer PR, Vansteensel MJ, Bleichner MG, Hermes D, Ferrier CH, Aarnoutse EJ, et al. Mismatch between electrocortical stimulation and electrocorticography frequency mapping of language. Brain Stimul. 2013;6(4):524–31.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    So EL, Alwaki A. A guide for cortical electrical stimulation mapping. J Clin Neurophysiol. 2018;35(2):98–105.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Duffau H, Capelle L, Denvil D, Sichez N, Gatignol P, Taillandier L, et al. Usefulness of intraoperative electrical subcortical mapping during surgery for low-grade gliomas located within eloquent brain regions: functional results in a consecutive series of 103 patients. J Neurosurg. 2003;98(4):764–78.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    De Witte E, Satoer D, Robert E, Colle H, Verheyen S, Visch-Brink E, et al. The Dutch linguistic intraoperative protocol: a valid linguistic approach to awake brain surgery. Brain Lang. 2015;140:35–48.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    De Witte E, Marien P. The neurolinguistic approach to awake surgery reviewed. Clin Neurol Neurosurg. 2013;115(2):127–45.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Shinoura N, Yoshida M, Yamada R, Tabei Y, Saito K, Suzuki Y, et al. Awake surgery with continuous motor testing for resection of brain tumors in the primary motor area. J Clin Neurosci. 2009;16(2):188–94.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Shinoura N, Yamada R, Tabei Y, Saito K, Suzuki Y, Yagi K. Advantages and disadvantages of awake surgery for brain tumours in the primary motor cortex: institutional experience and review of literature. Br J Neurosurg. 2011;25(2):218–24.PubMedCrossRefPubMedCentralGoogle Scholar
  68. 68.
    Shinoura N, Midorikawa A, Yamada R, Hana T, Saito A, Hiromitsu K, et al. Awake craniotomy for brain lesions within and near the primary motor area: a retrospective analysis of factors associated with worsened paresis in 102 consecutive patients. Surg Neurol Int. 2013;4:149.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    Yuan Y, Peizhi Z, Xiang W, Yanhui L, Ruofei L, Shu J, et al. Intraoperative seizures and seizures outcome in patients underwent awake craniotomy. J Neurosurg Sci. 2019;63(3):301–7.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Nossek E, Matot I, Shahar T, Barzilai O, Rapoport Y, Gonen T, et al. Intraoperative seizures during awake craniotomy: incidence and consequences: analysis of 477 patients. Neurosurgery. 2013;73(1):135–40; discussion 140.PubMedCrossRefGoogle Scholar
  71. 71.
    Bernstein M. Outpatient craniotomy for brain tumor: a pilot feasibility study in 46 patients. J Can Sci Neurol. 2001;28(2):120–4.CrossRefGoogle Scholar
  72. 72.
    Carrabba G, Venkatraghavan L, Bernstein M. Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg. 2008;51(4):208–10.PubMedCrossRefGoogle Scholar
  73. 73.
    Venkatraghavan L, Bharadwaj S, Au K, Bernstein M, Manninen P. Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study. Can J Anaesth. 2016;63(11):1245–57.PubMedCrossRefGoogle Scholar
  74. 74.
    van Ark TJ, Klimek M, de Smalen P, Vincent A, Stolker RJ. Anxiety, memories and coping in patients undergoing intracranial tumor surgery. Clin Neurol Neurosurg. 2018;170:132–9.PubMedCrossRefGoogle Scholar
  75. 75.
    Milian M, Tatagiba M, Feigl GC. Patient response to awake craniotomy—a summary overview. Acta Neurochir. 2014;156(6):1063–70.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    Beez T, Boge K, Wager M, Whittle I, Fontaine D, Spena G, et al. Tolerance of awake surgery for glioma: a prospective European low grade glioma network multicenter study. Acta Neurochir. 2013;155(7):1301–8.PubMedCrossRefGoogle Scholar

Suggested Reading

  1. Eseonu CI, ReFaey K, Garcia O, John A, Quinones-Hinojosa A, Tripathi P. Awake craniotomy anesthesia: a comparison of the monitored anesthesia care and asleep-awake-asleep techniques. World Neurosurg. 2017;104:679–86.PubMedCrossRefGoogle Scholar
  2. Ladino LD, Rizvi S, Tellez-Zenteno JF. The Montreal procedure: the legacy of the great Wilder Penfield. Epilepsy Behav. 2018;83:151–61.CrossRefGoogle Scholar
  3. Meng L, McDonagh DL, Berger MS, Gelb AW. Anesthesia for awake craniotomy: a how-to guide for the occasional practitioner. Can J Anaesth. 2017;64(5):517–29.PubMedCrossRefPubMedCentralGoogle Scholar
  4. Milian M, Tatagiba M, Feigl GC. Patient response to awake craniotomy—a summary overview. Acta Neurochir. 2014;156(6):1063–70.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Department of AnesthesiologyVanderbilt University Medical CenterNashvilleUSA

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