CRANIAL NEUROSURGERY SIMULATORS
CRANIAL NEUROSURGERY SIMULATORS
TOPIC
Virtual Reality–Based Simulation Training for
Ventriculostomy: An Evidence-Based Approach
Clemens M. Schirmer, MD,
PhD*‡
J. Bradley Elder, MD§
Ben Roitberg, MD¶
Darlene A. Lobel, MDk
*Division of Neurosurgery, Baystate Medical Center, Springfield, Massachusetts;
‡Department of Neurosurgery, Tufts
University School of Medicine, Boston,
Massachusetts; §Department of Neurological Surgery, The Ohio State University
Medical Center, Columbus, Ohio; ¶Section
of Neurosurgery, University of Chicago,
Chicago, Illinois; kDepartment of Neurologic Surgery, Mayo Clinic, Rochester,
Minnesota
Correspondence:
Clemens M. Schirmer, MD, PhD,
Baystate Medical Center Neurosurgery,
Department of Neurosurgery,
Tufts University School of Medicine,
2 Medical Center Drive, Ste 503,
Springfield, MA 01107.
E-mail: cmschirmer@gmail.com
Received, April 18, 2013.
Accepted, June 25, 2013.
Copyright ª 2013 by the
Congress of Neurological Surgeons
BACKGROUND: Virtual reality (VR) simulation-based technologies play an important
role in neurosurgical resident training. The Congress of Neurological Surgeons (CNS)
Simulation Committee developed a simulation-based curriculum incorporating VR
simulators to train residents in the management of common neurosurgical disorders.
OBJECTIVE: To enhance neurosurgical resident training for ventriculostomy placement
using simulation-based training.
METHODS: A course-based neurosurgical simulation curriculum was introduced at the
Neurosurgical Simulation Symposium at the 2011 and 2012 CNS annual meetings. A
trauma module was developed to teach ventriculostomy placement as one of the
neurosurgical procedures commonly performed in the management of traumatic brain
injury. The course offered both didactic and simulator-based instruction, incorporating
written and practical pretests and posttests and questionnaires to assess improvement
in skill level and to validate the simulators as teaching tools.
RESULTS: Fourteen trainees participated in the didactic component of the trauma
module. Written scores improved significantly from pretest (75%) to posttest (87.5%;
P , .05). Seven participants completed the ventriculostomy simulation. Significant
improvements were observed in anatomy (P , .04), burr hole placement (P , .03), final
location of the catheter (P = .05), and procedure completion time (P , .004). Senior
residents planned a significantly better trajectory (P , .01); junior participants improved
most in terms of identifying the relevant anatomy (P , .03) and the time required to
complete the procedure (P , .04).
CONCLUSION: VR ventriculostomy placement as part of the CNS simulation trauma
module complements standard training techniques for residents in the management of
neurosurgical trauma. Improvement in didactic and hands-on knowledge by course
participants demonstrates the usefulness of the VR simulator as a training tool.
KEY WORDS: Education, Neurotrauma, Residency, Simulation, Ventriculostomy, Virtual reality
Neurosurgery 73:S66–S73, 2013
DOI: 10.1227/NEU.0000000000000074
V
irtual reality (VR)–based simulators offer
an engaging method to complement standard neurosurgical resident training techniques. Such technology provides trainees with the
opportunity to rehearse commonly encountered
procedures outside a patient care setting, providing
extended opportunities to enhance surgical skills
ABBREVIATIONS: CA, Cochran-Armitage; CNS,
Congress of Neurological Surgeons; PGY, postgraduate year; VR, virtual reality
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
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and to improve patient safety profiles. The Accreditation Council for Graduate Medical Education
has instituted a requirement to incorporate
simulation-based training into general surgery
training programs.1 Additionally, evaluation of
resident skills using simulators has been proposed
as the basis for credentialing for certain procedures
such as carotid angioplasty and stenting.2 Even
though the use of simulators has previously been
identified as part of the educational agenda for
neurosurgical education,3 the complex nature of
neurosurgical procedures and the need for simulators that can provide essential haptic feedback
have limited the implementation of simulationbased technologies into neurosurgical resident
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SIMULATION TRAINING IN NEUROSURGICAL TRAUMA
training programs. Recent technological advances in simulator
development, combined with a greater understanding of how best
to integrate simulator-based instruction into formal curricula, have
led the Congress of Neurological Surgeons (CNS) to develop a
neurosurgical simulation training program to enhance resident
education in the management of neurosurgical disorders.
Ventriculostomy placement is among the most commonly encountered procedures in resident training, typically learned in the first few
months of postgraduate training and often performed unsupervised
thereafter. Often, placement of a ventriculostomy is taught to junior
residents by more senior residents in an apprenticeship model during
a neurosurgical emergency, causing significant obstacles to meaningful
learning resulting from the stress of an emergency situation combined
with minimal prior hands-on experience, which may increase the risk
of surgical complications. Simulation-based training for ventriculostomy placement early in residency training may improve resident skills
and patient outcomes by transferring the learning curve from the
operating room to the simulation center, a shift not unprecedented in
procedure-based medical specialties.2 Both physical and VR-based
ventriculostomy models have been developed.4 Early validation data
for the ImmersiveTouch virtual ventriculostomy model suggest that
improved rates of ventricular cannulation were observed after use of
the VR-based simulator.5
The CNS has developed a trauma module as part of the resident
simulation curriculum that focuses on teaching skills necessary to
performance of the most common surgical procedures in the treatment
of neurotrauma-based injuries. This module was presented as part of
the CNS Resident Simulation Symposium at the 2011 and 2012 CNS
annual meetings. This article analyzes the deployment, performance,
and validity of a VR-based ventriculostomy simulator presented as
a component of the trauma module, with structured surveys,
didactic and hands-on instruction, and written and practical tests.
METHODS
The trauma module of the CNS Resident Simulation Symposium was
developed using a curriculum-based approach to educate neurosurgical
trainees in skills necessary for the management of traumatic brain injury.
Simulators incorporated into this module were chosen to meet educational goals. Didactic training and hands-on training were integrated into
the session. Validation of the simulators and course design were assessed
with well-defined evaluation tools.
Choice of Simulators
The CNS trauma simulation team conducted an evaluation of
commercially available ventriculostomy simulators. Two ventriculostomy
simulators were identified, including a physical simulator (University of
Florida, Gainesville, Florida) that was in development but not yet ready for
commercialization.6 A VR-based ventriculostomy simulator (ImmersiveTouch, Chicago, Illinois) was chosen for the course on the basis of its prior
use in resident training forums and the validation capabilities that are
integrated into the system. The ventriculostomy system (Figure 1) is an
augmented VR system that integrates a haptic device and a highresolution, high-pixel-density stereoscopic display.4 Using a head and hand
tracking system, the system scores several performance measures, including
NEUROSURGERY
FIGURE 1. ImmersiveTouch (ImmersiveTouch, Chicago, Illinois) virtual
reality–based ventriculostomy simulator.
entry point for the burr hole, catheter trajectory, length of catheter
inserted, and distance of catheter tip from the foramen of Monro.
Course Design
The trauma module was designed to conform with guidelines
established for all modules in the CNS Resident Simulation Symposium.
This included a precourse questionnaire to assess familiarity with
simulators and questions that the participants were asked to self-assess
their existing experience with performing craniotomies for trauma and
placing ventriculostomies. The answers were stratified into a low
experience level for , 50 procedures done and , 50% reported
autonomy and a high level for . 50 procedures and . 50% autonomy.
Self-reported time for completing a ventriculostomy was stratified into
a fast group for , 30 minutes and a slow group for , 30 minutes.
A written pretest assessed knowledge of relevant neuroanatomy and
traumatic brain injury management skills. Participants then attended
a didactic session to reinforce critical concepts. A written posttest, which
included the same questions as the pretest, was administered at the
conclusion of the module.
After participating in the didactic portion of the course, participants
were assigned to the virtual ventriculostomy simulator session. This
portion of the course included a 10-minute demonstration of simulator
use, followed by a hands-on practical pretest to assess baseline skill level.
The faculty grading this pretest assessed the participant’s knowledge of
anatomy and technical skills during performance of the procedure. The
pretest was followed by hands-on training with the same faculty
instructor; then participants were allowed 45 minutes of independent
practice time. A practical posttest was administered using the same
scoring metrics applied during the practical pretest. Hands-on training
was followed by an immediate postcourse evaluation with the entire
cohort. At 6 months after the course, a final questionnaire was sent to
participants to evaluate how attending the course may have affected their
skill and comfort levels with common neurosurgical procedures.
Evaluation Tools
Written pretests and posttests were assigned ordinal scores on the basis
of the number of correct responses of 12 questions administered. A
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SCHIRMER ET AL
technical assessment form, based on the objective structured assessment of
technical skill,7 was developed to evaluate hands-on skills and to validate
the simulator. Additionally, certain evaluation measures were calculated
by a software program as part of the ventriculostomy simulator itself,
allowing precise data collection and unbiased assessment of the following
components: trajectory, depth and final location of catheter, and time to
complete procedure. Other performance measures included knowledge
of anatomy and landmarks, dexterity in instrument use, and technical
skills (Table). Data for these assessments were acquired in real time and
entered into a tablet database program. For each simulation, there was
a training instance or trial run, followed by one-on-one interaction with
a faculty member who provided instruction and critique. This was
followed by an evaluation instance or final run. Ordinal scores between
1 and 5 were given for each performance measure. Scores 2 and 4 were
interpolated between the end points given in the Table for scores of 1,
3 and 5. See the Table for definition of performance measures. Participants
were classified on the basis of their level of training into a junior group
encompassing medical students and residents in postgraduate years (PGY1-PGY3) and a senior group with residents in PGY-4 to PGY-7.
Ordinal performance measures were analyzed by the use of contingency
tables and Pearson x2 tests and asymptotic Cochran-Armitage (CA) test
for trends. Statistical analysis was performed with SAS JMP (SAS
Institute, Carey, North Carolina). Pretest and posttest data were then
evaluated to assess the validity of the 2 simulators as teaching tools.
RESULTS
A cohort of 15 participants was enrolled in the trauma module
of the CNS neurosurgery simulation course at the 2012 CNS
national meeting. Fourteen participants, all at the time of the
course enrolled in postgraduate training in neurological surgery in
either a US- or Canada-based institution (5 participants) or at
foreign institutions (9 participants) as a resident or fellow,
underwent structured teaching and testing in this second iteration
of the course. Participant experience ranged from PGY-1 to PGY-7
level. One person did not arrive for the course.
Seven of 12 participants (58%) submitted answers to questions in
the precourse questionnaire to assess their existing experience levels.
Self-reported experience levels correlated well with the PGY level;
receiver-operating curves had areas . 0.92 (P , .005), allowing the
use of the PGY level as a surrogate marker for experience.
Written Test Performance
Fourteen participants took the pretest and were exposed to the
structured educational materials in the form of a lecture and
presentation; then, selected participants completed the hands-on
simulation of a ventriculostomy placement followed by a posttest,
which was completed by 12 participants (86% completion rate).
The data analysis incorporates only the 12 participants who
completed the entire course, including both pretests and posttests,
instruction, and hands-on components.
The median number of correct answers in the pretest was 9 of
12 (75%), and the median time taken to complete the test was
4 minutes 3 seconds. After didactic instruction and completion of
the simulator, the median number of correct answers increased to
10.5 of 12 (87.5%), a significant improvement (P , .05). The
time taken by participants to answer the test significantly
improved to a median of 3 minutes 15 seconds (22% mean
improvement; P , .02; see Figure 2A and 2B).
We analyzed the subset of 5 questions concerning ventriculostomyrelated knowledge. Test participants improved significantly after
instruction, from 75% correct answers to 83.3% (P , .01; see
Figure 2C).
Simulation Performance
Ten participants completed the virtual ventriculostomy simulation and improved in all performance measures (Figure 3).
Anatomy and landmarks were correctly described by 86% of
participants, significantly improved from 29% after a trial run
(P = .17; CA test, P , .04). The burr hole placement was ideal by
TABLE. Ordinal Performance Evaluation for Simulated Virtual Ventriculostomy Placementa
Score
1
Anatomy and
landmarks
Did not define critical landmarks
and structures
Burr hole
Burr hole placed along midline
placement
or posterior to coronal suture
Trajectory of
Traverses midline or passes
catheter insertion
through critical structures
a
, 3 or . 9 cm
Depth of catheter
insertion
Final location of
catheter tip
Catheter not positioned in
ventricle
Time to complete
procedure
Unable to complete procedure
in allotted time
2
3
4
5
Identified either midline or coronal
suture but not both
Identified all critical landmarks
and structures
Burr hole placed too laterally or
too anteriorly
Too lateral or too medial but avoids
critical structures
Burr hole at the Kocher point
4-5 or 6-7 cm
Catheter in center of ipsilateral ventricle
or in contralateral ventricle
10 min
Ideal path, avoiding all critical
structures
5-6 cm
Tip within 5 mm of ipsilateral
foramen of Monroe
, 5 min
Ordinal scores between 1 and 5 were given for each performance measure; scores of 2 and 4 were interpolated between the end points given in the Table for scores of 1, 3, and 5.
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SIMULATION TRAINING IN NEUROSURGICAL TRAUMA
FIGURE 2. Results of the preinstruction and postinstruction multiple-choice test. A, percent of correct answers across the entire test; B, time to completion; and C, percent of
correct answers for the subset of ventriculostomy-related questions. All differences are statistically significant. EVD, external ventricular drain.
the same 86% of participants, significantly improved from 29%
(these 2 participants were different from the 2 who scored well in
the previous performance submeasure; P = .09; CA test, P , .03).
The trajectory of the ventriculostomy insertion was deemed ideal
in 57%, not significantly improved from 29% (P = .33; CA test,
P = .24), again reflecting that some participants did worse after
the trial run. There was a trend toward placing the ventriculostomy at the appropriate depth of exactly 5 to 6 cm; notably only
29% of participants achieved this, although this improved from
14% (P = .13; CA test, P = .08). The final location of the catheter
tip was judged as ideal in 43%, significantly improved from 14%
(P = .24; CA test, P = .05). Eighty-six percent of participants were
able to complete the virtual procedure in , 5 minutes, whereas
no participants were able to achieve this in the trial run, with 71%
requiring just under 10 minutes to complete all steps, demonstrating a significant improvement (P , .004; CA test, P , .02).
FIGURE 3. Course participants were evaluated for baseline hands-on skill level and after one-on-one training with the
ventriculostomy simulator on a 5-point scale. Posttraining improvement in each of the 6 evaluation measures was observed.
Statistically significant improvements were noted in the description of anatomy and landmarks, burr hole placement, final
catheter tip location, and time to completion. EVD, external ventricular drain.
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SCHIRMER ET AL
Results Stratification by Training Level
We analyzed the performances in the written tests and on the
simulator, hypothesizing that junior participants would initially do
worse and show more improvement and vice versa for senior
participants, and to confirm the finding of a plateau at the PGY-5
level in a previous study.8
Junior participants took initially less time to complete the written
pretest compared with their more senior colleagues (average
difference, 22 seconds). In the posttest, the senior participants took
less time (mean difference, 45 seconds), for a significant improvement on the side of the senior participants (P , .02, matched pairs).
Junior participants unexpectedly answered more questions correctly
in the pretest (79% vs 75%) and improved more in the posttest
(89% vs 81%), amounting to a significant 11% improvement
(P . .01, matched pairs). There was a similar trend when only the
external ventricular drain–related questions were analyzed (77.5%
vs 70% in the pretest for junior vs senior participants, 10% vs 20%
improvement for junior vs senior participants in the posttest).
For the ventriculostomy simulator, senior residents planned
a significantly better trajectory (P , .01; CA test, P = .27) but did
not otherwise outperform more junior participants in assessments
of anatomic knowledge (P = .47; CA test, P = .13), burr hole
placement (P = .4; CA test, P = .5), depth of insertion (P = .58; CA
test, P = .39), final catheter location (P = .18; CA test, P = .19), and
time to complete the procedure (P = .62; CA test, P = .42). Junior
residents improved significantly in the performance measures
testing the relevant anatomy (P = .21; CA test, P , .03) and the
time required to complete the procedure (P = .13; CA test, P ,
.04). There was no significant improvement in measures for burr
hole placement (P = .38; CA test, P = .1), trajectory (P = .14; CA
test, P = .27), and catheter depth (P = .39; CA test, P = .37). Senior
residents demonstrated greater improvement in the final catheter
tip location on their second attempt (P , .05; CA test, P = .19;
Figure 4A).
Data analysis of the performance of the trainees affirms
construct validity of the ventriculostomy simulator. Postcourse
evaluations revealed that participants enjoyed the ventriculostomy
simulator and felt it was an effective teaching tool, supporting face
and content validity. More definitive statistical analyses regarding
face and content validity are limited because of the small number
of participants completing the postcourse questionnaire.
DISCUSSION
There have been previous attempts at simulating ventriculostomy placement. A Web-based simulator introduced in 2000
FIGURE 4. A, change in scores for each of the evaluation measures for both the craniotomy simulator and the ventriculostomy simulator, stratified by postgraduate year (PGY)
level. The greatest improvement was observed during the course for the most junior-level residents. B, cumulative improvement (score difference after instruction) by PGY level.
C, cumulative score by PGY level (blue, before instruction; red, after instruction). EVD, external ventricular drain.
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SIMULATION TRAINING IN NEUROSURGICAL TRAUMA
provided auditory feedback; however, its use was limited by
technical drawbacks, including a lack of haptic feedback and use of
a mouse-driven pointer to direct the catheter trajectory.9,10
Neuronavigation has been used to simulate the catheter position
and to study this position relative to the adjacent anatomy.
Although this technique was shown to help young neurosurgeons
understand anatomic relationships, it does not represent a true
simulation of the procedure.11 A first attempt at introducing
haptic technology to ventriculostomy simulators was made by
a group using the Reachin VR-haptic display (Reachin Technologies AB, Stockholm, Sweden).12 A Swiss group took a
different approach and developed a 1-df model to simulate the
advancement of a catheter into a physical brain model using the
BrainTrain simulator (Sensory Motor Systems Laboratory,
Zurich, Switzerland).13 Using the physical model obviates the
need for rendering VR graphics, but concerns about the internal
validity of this particular simulator have been raised.14
The introduction of neurosurgical simulation programs to aid
in the training of neurosurgeons and neurosurgical residents is
gaining importance as a strategy to address deficiencies in certain
areas of neurosurgical education3,15 and to provide supplemental
training for surgical residents who now face work hour
restrictions. As simulation technology improves, a growing
percentage of neurosurgical training programs in the United
States are likely to incorporate simulator-based training to meet
these educational needs and to address patient safety concerns.16
As discussed by Lobel et al17 in the article describing the trauma
craniotomy simulator in this supplement, there is a relative
paucity of peer-reviewed neurosurgical literature compared with
general surgery literature regarding simulation-based training in
surgical procedures. As neurosurgical simulator technologies evolve,
validation of these simulators as effective teaching tools is required
before widespread use as adjuncts to residency training. Concepts in
simulator validation previously described in the general surgery
literature can be applied to neurosurgical simulator technology.
These validation concepts include construct, face, and content
validation techniques18,19 and have been applied to validating
haptics simulators20,21 and VR devices.22 Face validity and content
validity are determined by assessing how closely a simulator appears
to replicate the task being simulated among novices and experts,
respectively. Construct validity refers to the degree to which
a simulator is able to predict the level of expertise of the participant
on the basis of their performance in the simulated task. We sought
here to validate the ventriculostomy portion of the trauma module
described on the basis of these concepts in validation.
The VR ventriculostomy simulator was able to predict the level
of expertise on the basis of the trajectory chosen for passing the
catheter but not for other metrics evaluated. This may indicate that
ventriculostomy is a clinical task learned early in residency or even
medical school and that junior residents may benefit more than
senior residents from the training paradigm described here.
Alternatively, categorization of simulator participants into PGY-1
to -3 and PGY-4 to -7 groups may be too broad to sense differences
in expertise. A larger cohort of participants would have increased the
NEUROSURGERY
power of the study and may have allowed identification of the
training year in which the learning curve plateaus for each of
the metrics in this simulator. In a previous study, a plateau was noted
at the PGY-5 year.8 Results of our study reveal a similar trend
(Figure 4B and 4C), supporting construct validity of the
ventriculostomy simulator.
Participants in the trauma module were asked their opinions
regarding the ability of the simulator to improve their technical
skills and their likelihood to recommend the trauma simulation
course to other trainees. Analysis of responses showed a trend
indicating that the trauma simulators engaged the participants in
tasks they felt were relevant to their training, supporting the face
validity of the simulator, although the number of responses to the
questionnaire was insufficient for statistical evaluation.
The participants completed the ventriculostomy simulator in
the neurosurgery trauma module in a reasonable period of time.
Data regarding time to completion and scores from the judges
indicate that the simulators generated consistent results among the
participants. When repeating a simulator trial, participants
typically have significantly improved performance, underscoring
the potential for positive educational impact, although the
durability of this effect is unknown.
In prior reports, the validity of a training module is commonly
assessed by evaluating results from a small group of trainees
performing the course23 and using surrogate measures of
success.24 The neurosurgical trauma simulation course describes
a similarly sized group of neurosurgical trainees enrolled in an allday simulation course. On the basis of the performance of the
trainees and their postcourse feedback, the validity of the
ventriculostomy simulator when used within the framework of
the module is suggested. However, this will need to be more
conclusively demonstrated with further testing.
A number of alternative simulators exist9,10,12 that simulate
either part-tasks of or the entire ventriculostomy procedure.
Because of limitations of VR-based technology in earlier years,
models often incorporate a physical component along with the
VR components.6,13 Our simulator has a number of features that
replicate tasks that increase the realism of the simulation
tremendously, eg, the ability to manipulate the head position
and an overlay between the stylus and the virtual catheter.
Limitations of the fidelity of the simulation include simplified
steps involved in creating the skin incision because bleeding skin
vessels can pose problems for junior trainees without readily
available cautery. Additional limitations include the lack of
a realistic bony sidewall of the burr hole, which may affect
directional guidance on the catheter, and the lack of simulating the
procedure of tunneling the catheter under the skin without
moving the catheter tip from the final location.
A few limitations of the design of the ventriculostomy
simulation module must be noted. Although some evaluation
measures are amenable to concrete analysis such as knowledge of
anatomy and conceptual understanding of the procedure, others,
including dexterity and ventriculostomy trajectory, are sensitive to
interattempt variations, and improvement in these measure may
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SCHIRMER ET AL
not be observed over such a short training regimen. Therefore,
there is potential for participants to obtain a poorer score in the
final attempt after a good score in the trial run. One method to
address these concerns is the introduction of regional simulation
courses in addition to the annual CNS Resident Simulation
Symposium, which will improve data analysis by incorporating
greater numbers of participants. This will also allow us to
overcome the inherent limitation of the small numbers in our
data set, which limit the power of the analysis. Despite small
numbers, we attempted to stratify the data in a reasonable manner
to allow analysis pertaining to simulator validity, but we underline
that the small number of participants limits such a stratification.
Future work will attempt to increase the number of data points and
will evaluate the relative importance of distinct part-task components for the completion of the entire task.
One drawback of high-fidelity VR simulators, in general, is
a rather large upfront cost. Even though maintenance and use costs
are typically much lower, they are still considerable and often
include fees for personnel. The estimated cost for the ventriculostomy simulator purchase is significant, with purchase options
beginning at $75 000 and lease options at $20 000.
The trauma module as a component of the CNS Resident
Simulation Symposium is currently undergoing evaluation by the
course directors to optimize educational benefit and validation
analysis and to minimize cost.
The use of simulation could, for example, be used in conjunction
with credentialing models, which require junior residents to
perform a number of ventriculostomies under supervision to the
satisfaction of the faculty before being allowed unsupervised
performance. This would follow a pathway outlined by the example
of central line placement where the training algorithm changed from
one of supervised learning on patients to manikin-based practice
requiring proficiency before patient interaction was permitted at the
earliest stages of postgraduate education.25 We could therefore
imagine the deployment of this module within the framework of
the national fundamentals curriculum of the Society of Neurological Surgeons boot camp courses26 in which a large number of
residents meet or in dedicated neurosurgical dissection and
simulation laboratories.
CONCLUSION
The trauma module of the CNS simulation course was designed
to introduce neurosurgical trainees to a simulation-based curriculum
to teach skills relevant to the management of traumatic brain injury.
Data analysis from the 2012 course reveals that the ventriculostomy
simulator, as part of the trauma module, is a valid method to enhance
resident training. At both the 2011 and 2012 meetings, the number
of participants in this course was necessarily limited by the availability
of simulators and faculty to provide a one-on-one training
experience. Further data and additional simulators at future courses
will allow improved validation measures for the module.
A podcast related to this article can be accessed online
(http://links.lww.com/NEU/A574).
S72 | VOLUME 73 | NUMBER 4 | OCTOBER 2013 SUPPLEMENT
Disclosures
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article. Information detailed in this
article has been submitted as an abstract to the 2013 CNS Annual Meeting.
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