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Abstract

Objective:

To visualize and treat spinal dural CSF leaks in all patients with intractable spontaneous intracranial hypotension (SIH) who underwent spinal microsurgical exploration.

Methods:

Patients presenting between February 2013 and July 2015 were included in this consecutive case series. The workup included spinal MRI without and with intrathecal contrast, dynamic myelography, postmyelography CT, and microsurgical exploration.

Results:

Of 69 consecutive patients, 15 had intractable symptoms. Systematic imaging revealed a suspicious single location of the leak in these 15 patients. Fourteen patients underwent microsurgical exploration; 1 patient refused surgery. Intraoperatively, including intradural exploration, we identified the cause of the CSF leaks as a longitudinal dural slit (6.1 ± 1.7 mm) on the ventral (10), lateral (3), or dorsal (1) aspect of the dura. In 10 patients (71%), a ventral, calcified microspur originating from the intervertebral disk perforated the dura like a knife. Three patients (22%) had a lateral dural tear with an associated spinal meningeal diverticulum, and in 1 patient (7%), a dorsal osteophyte was causal. The microspurs were removed and the dural slits sutured with immediate cessation of CSF leakage.

Conclusion:

The nature of the CSF leak is a circumscribed longitudinal slit at the ventral, lateral, or dorsal dura mater. An extradural pathology, diskogenic microspurs, was the single cause for all ventral CSF leaks. These findings challenge the notion that CSF leaks in SIH are idiopathic or due to a weak dura. Microsurgery is the treatment of choice in cases with intractable SIH.

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Supplementary Material

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Information & Authors

Information

Published In

Neurology®
Volume 87Number 12September 20, 2016
Pages: 1220-1226
PubMed: 27566748

Publication History

Received: January 18, 2016
Accepted: June 9, 2016
Published online: August 26, 2016
Published in print: September 20, 2016

Permissions

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Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Study Funding

The Department of Neurosurgery, University Hospital, University of Bern funded the study.

Authors

Affiliations & Disclosures

Jürgen Beck, MD*
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
(1) Boehringer Ingelheim
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
(1) transdermal pointer for neuronavigation, PCT/EP2014/056340
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Swiss National Science Foundation (SNF) #320030 135477 Swiss National Science Foundation (SNF) #150009
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Swiss Heart Foundation, SWITCH Insel-Grant
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Christian T. Ulrich, MD*
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Christian Fung, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Swiss Heart Foundation Inselspital Foundation
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Jens Fichtner, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Brainlab AG
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Kathleen Seidel, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Michael Fiechter, PhD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Kety Hsieh, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Michael Murek, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
(1) Brainlab AG
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
David Bervini, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Niklaus Meier, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
(1) Merz Pharma
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
(1) Ipsen Pharma, funding for travel to a scientific Meeting, (2) Bayer Healthcare, speaker honoraria
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Marie-Luise Mono, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Swiss Heart Foundation, Grant
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Pasquale Mordasini, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Ekkehard Hewer, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Werner J. Z'Graggen, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
Swiss Foundation for Research on Muscle Diseases
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Jan Gralla, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
DSMB member for the Promise Study (Study on ischemic stroke, Sponsor: Penumbra)
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Speakers honoraria since 2014 from Covidien
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Former global PI of the STAR Study (strokeGlobal PI of the SWIFT Direct Trial (stoke)), therefore Consultant for Covidien
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Andreas Raabe, MD
From the Departments of Neurosurgery (J.B., C.T.U., C.F., J.F., K.S., M.F., M.M., D.B., W.J.Z., A.R.), Neuroradiology (K.H., P.M., J.G.), Neurology (N.M., M.-L.M., W.J.Z.), and Neuropathology (E.H.), Inselspital, University Hospital, University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Beck: [email protected]
*
These authors contributed equally to this work.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

J.B. and C.T.U. contributed to writing, data interpretation, data analysis, data collection, study design, figures, literature search, and article submission. C.F. provided writing, data interpretation, data analysis, and literature search. J.F. contributed to data interpretation, data analysis, data collection, figures, and literature search. K.S., M.F., K.H., M.M., N.M., M.-L.M., P.M., E.H., and J.G. provided data interpretation, data analysis, and data collection. D.B. performed data interpretation, literature search, and literature review. W.J.Z. provided writing, data interpretation, data analysis, and data collection. A.R. contributed to writing, data interpretation, data analysis, and study design.

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