Abstract TP457: Intraventricular and Intravenous Milrinone for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Meghan Purohit ◽  
Naresh Mullaguri ◽  
Christine Ahrens ◽  
Christopher Newey ◽  
Dani Dhimant ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Demographic Data ◽  
Case Series ◽  
Standard Of Care ◽  
Mean Flow ◽  
First Case ◽  
Fisher Grade ◽  
Tertiary Center

Introduction: Cerebral vasospasm (CVS) is a complication of aneurysmal subarachnoid hemorrhage (aSAH). Intraventricular milrinone (IVtM) and intravenous milrinone (IVM) have been studied for treatment of CVS. We aimed to determine the effect of milrinone therapy on clinical and transcranial Doppler (TCD) measures of CVS. Methods: We performed a retrospective analysis of patients with aSAH treated with IVtM at a single tertiary center between 2016 and 2018. Patients were treated with IVtM if they had symptomatic CVS or TCD suggestive of critical CVS that persisted despite blood pressure augmentation or endovascular therapies. Nimodipine was given as standard of care. A subset of patients were also treated with IVM, which was dosed in a standard fashion based on Montreal Neurological Institute protocol. We collected demographic data, TCD mean flow velocity and pulsatility index, angiographic data, as well as utilization and frequency of IVtM and IVM. Results: Twenty-eight patients in our cohort had modified Fisher grade 4 (57%) or grade 3 (25%) and median Hunt-Hess score of 3 (IQR 2, 4). Twenty-one of 28 patients were treated with IVtM+IVM. Seven (25%) who received IVtM alone had no significant improvement in TCD velocities or reduction in symptomatic CVS (p=0.611). Patients received between 1 and 30 doses of IVtM. There was no significant improvement with time or with number of IVtM doses IVtM. There was also no significant improvement in TCD velocities of CVS patients nor reduction in symptomatic CVS with IVtM+IVM (p=0.69). The number of IVtM doses correlated with an increased discharge mRS (p=0.05). There were no direct complications due to IVtM or IVM. Conclusion: Neither IVtM+IVM nor IVtM alone appear to be effective treatment of CVS in aSAH. Our data represent one of the first case series reporting IVtM and IVtM+IVM utilization for the treatment of CVS.

Length of hospital stay in aneurysmal subarachnoid hemorrhage patients without vasospasm on angiography: potential for a fast-track discharge cohort

2021 ◽  
pp. neurintsurg-2021-017424
Author(s):  
Joshua S Catapano ◽  
Visish M Srinivasan ◽  
Kavelin Rumalla ◽  
Mohamed A Labib ◽  
Candice L Nguyen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Length Of Hospital Stay ◽  
Hospital Length Of Stay ◽  
Neurologic Outcome ◽  
Angiographic Vasospasm ◽  
Fisher Grade ◽  
Tertiary Center

BackgroundPatients with aneurysmal subarachnoid hemorrhage (aSAH) frequently suffer from vasospasm. We analyzed the association between absence of early angiographic vasospasm and early discharge.MethodsAll aSAH patients treated from August 1, 2007, to July 31, 2019, at a single tertiary center were reviewed. Patients undergoing diagnostic digital subtraction angiography (DSA) on post-aSAH days 5 to 7 were analyzed; cohorts with and without angiographic vasospasm (angiographic reports by attending neurovascular surgeons) were compared. Primary outcome was hospital length of stay; secondary outcomes were intensive care unit length of stay, 30 day return to the emergency department (ED), and poor neurologic outcome, defined as a modified Rankin Scale (mRS) score >2.ResultsA total of 298 patients underwent DSA on post-aSAH day 5, 6, or 7. Most patients (n=188, 63%) had angiographic vasospasm; 110 patients (37%) did not. Patients without vasospasm had a significantly lower mean length of hospital stay than vasospasm patients (18.0±7.1 days vs 22.4±8.6 days; p<0.001). The two cohorts did not differ significantly in the proportion of patients with mRS scores >2 at last follow-up or those returning to the ED before 30 days. After adjustment for Hunt and Hess scores, Fisher grade, admission Glasgow Coma Scale score, and age, logistic regression analysis showed that the absence of vasospasm on post-aSAH days 5–7 predicted discharge on or before hospital day 14 (OR 3.4, 95% CI 1.8 to 6.4, p<0.001).ConclusionLack of angiographic vasospasm 5 to 7 days after aSAH is associated with shorter hospitalization, with no increase in 30 day ED visits or poor neurologic outcome.

scholarly journals Evaluation Of Intra-Arterial Nimodipine Therapy In Post-Subarachnoid Hemorrhage Refractory Cerebral Vasospasm

2021 ◽  
Author(s):  
Shrey Jain ◽  
Ajit Kumar Sinha ◽  
Sumit Goyal
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Neurological Assessment ◽  
Minimum Risk ◽  
Operative Morbidity ◽  
Fisher Grade ◽  
Grade 3 ◽  
Triple H

Abstract Background: Cerebral vasospasm is a major cause of morbidity and mortality in patients with subarachnoid hemorrhage. Vasospasm is managed with triple H and vasodilators but sometimes, patients do not respond. Intra-arterial vasodilator infusion has been shown to improve outcome in such patients. In this study, we try to evaluate the efficacy of intra-arterial nimodipine therapy in 43 patients of post-aneurysmal subarachnoid hemorrhage refractory cerebral vasospasm. Methods: It is a prospective observational study of a group of 43 patients presenting with refractory cerebral vasospasm as per the inclusion criteria. Pre-procedure neurological assessment and Transcranial Doppler (TCD) monitoring were done. Endovascular spasmolysis was conducted and post-operative morbidity and outcomes were noted. Follow up of the patients was done at the time of discharge and at 6 months according to the Modified Rankin Scale and NCCT head. Results: Most of the patients developing refractory cerebral vasospasm belonged to Hunt and Hess Grade 2 and 3 and Fisher grade 3 and 4. 87.5% of the patients showed clinical recovery following endovascular spasmolysis and 58% of the patients showed complete angiographic recovery. Outcome after 6 months was good in 76%, moderate in 12% and poor in 12% patients. NCCT head showed no infarct in 58%, minor infarct in 28% and major vascular territorial infarct in 14% patients. Conclusions: Intra-arterial nimodipine infusion is a safe and effective therapy with minimum risk of complications if adhered to standard endovascular practice. By timely intervention, major ischemic insult to the brain can be averted, thereby significantly improving the prognosis.

THERAPEUTIC HYPOTHERMIA IN PATIENTS WITH ANEURYSMAL SUBARACHNOID HEMORRHAGE, REFRACTORY INTRACRANIAL HYPERTENSION, OR CEREBRAL VASOSPASM

Neurosurgery ◽  
2009 ◽  
Vol 64 (1) ◽  
pp. 86-93 ◽  
Author(s):  
Martin A. Seule ◽  
Carl Muroi ◽  
Susanne Mink ◽  
Yasuhiro Yonekawa ◽  
Emanuela Keller
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Side Effects ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Cerebral Vasospasm ◽  
Conventional Treatment ◽  
Mild Hypothermia ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Poor Grade ◽  
Fisher Grade

Abstract OBJECTIVE To evaluate the feasibility and safety of mild hypothermia treatment in patients with aneurysmal subarachnoid hemorrhage (SAH) who are experiencing intracranial hypertension and/or cerebral vasospasm (CVS). METHODS Of 441 consecutive patients with SAH, 100 developed elevated intracranial pressure and/or symptomatic CVS refractory to conventional treatment. Hypothermia (33–34°C) was induced and maintained until intracranial pressure normalized, CVS resolved, or severe side effects occurred. RESULTS Thirteen patients were treated with hypothermia alone, and 87 were treated with hypothermia in combination with barbiturate coma. Sixty-six patients experienced poor-grade SAH (Hunt and Hess Grades IV and V) and 92 had Fisher Grade 3 and 4 bleedings. The mean duration of hypothermia was 169 ± 104 hours, with a maximum of 16.4 days. The outcome after 1 year was evaluated in 90 of 100 patients. Thirty-two patients (35.6%) survived with good functional outcome (Glasgow Outcome Scale [GOS] score, 4 and 5), 14 (15.5%) were severely disabled (GOS score, 3), 1 (1.1%) was in a vegetative state (GOS score, 2), and 43 (47.8%) died (GOS score, 1). The most frequent side effects were electrolyte disorders (77%), pneumonia (52%), thrombocytopenia (47%), and septic shock syndrome (40%). Of 93 patients with severe side effects, 6 (6.5%) died as a result of respiratory or multi-organ failure. CONCLUSION Prolonged systemic hypothermia may be considered as a last-resort option for a carefully selected group of SAH patients with intracranial hypertension or CVS resistant to conventional treatment. However, complications associated with hypothermia require elaborate protocols in general intensive care unit management.

Early Endovascular Coiling of Posterior Communicating Artery Saccular Aneurysm in the Setting of Staphylococcus Bacteremia

Neurosurgery ◽  
2010 ◽  
Vol 66 (4) ◽  
pp. E847-E847 ◽  
Author(s):  
Wilson Z. Ray ◽  
Michael N. Diringer ◽  
Christopher J. Moran ◽  
Gregory J. Zipfel
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Infectious Complications ◽  
Saccular Aneurysm ◽  
Posterior Communicating Artery ◽  
Endovascular Coiling ◽  
Coagulase Negative Staphylococcus ◽  
First Case ◽  
Fisher Grade ◽  
Increased Risk

Abstract OBJECTIVE Although infectious complications of endovascular aneurysm treatment are in general rare, platinum coil therapy for patients with ruptured cerebral aneurysms and active bacteremia could be expected to carry increased risk. The literature on the timing and safety of endovascular treatment in this setting, however, is limited. In this report, the authors present a case of aneurysmal subarachnoid hemorrhage and active bacteremia in which intravenous antibiotics and early endovascular therapy were successfully used. A review of the literature is also provided. CLINICAL PRESENTATION A 79-year-old woman presented with Hunt-Hess grade 4, Fisher grade 3 + 4 subarachnoid hemorrhage. Blood cultures obtained on admission revealed gram-positive cocci, which later proved to be coagulase-negative Staphylococcus. INTERVENTION Intravenous cefepime and vancomycin were begun soon after admission. A right posterior communicating artery saccular aneurysm was identified on diagnostic cerebral angiography and was treated with bare platinum coils 28 hours after antibiotic therapy was initiated. An extended course of vancomycin was completed. No intracranial infectious complications were noted at 34-month clinical and radiographic follow-up. CONCLUSION This is the first case report to document the efficacy and safety of early endovascular coil embolization of a ruptured saccular cerebral aneurysm presenting in the context of active bacteremia. Review of the available literature suggests that a similar strategy for ruptured infectious aneurysms may also be safe. Further validation of this approach for both saccular and infectious aneurysms, however, is required.

Intraventricular Tissue Plasminogen Activator for the Prevention of Vasospasm and Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2010 ◽  
Vol 67 (1) ◽  
pp. 110-117 ◽  
Author(s):  
Rohan Ramakrishna ◽  
Laligam N. Sekhar ◽  
Dinesh Ramanathan ◽  
Nancy Temkin ◽  
Danial Hallam ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Demographic Data ◽  
Test Analysis ◽  
Fisher Grade ◽  
Tissue Plasminogen ◽  
Cerebrospinal Fluid Shunting ◽  
Average Standard Error

Abstract BACKGROUND The sequelae of aneurysmal subarachnoid hemorrhage (SAH) include vasospasm and hydrocephalus. OBJECTIVE To assess whether intraventricular tissue plasminogen activator (tPA) results in less vasospasm, fewer angioplasties, or fewer cerebrospinal fluid shunting procedures. METHODS 41 patients (tPA group, Hunt and Hess 3, 4, 5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5–7 days) and were compared to a matched group of 35 patients from 2006 to 2007 (Control, HH 3, 4, 5). Statistical comparison was done by t test analysis or Fisher exact tests and data are expressed as average ± standard error of the mean. RESULTS There were no significant differences in demographic data, although the tPA group had a trend toward more surgical patients. The tPA group of patients had a significantly higher modified Fisher grade than controls (P &lt; .001) and had a significantly better Hunt and Hess grade than controls (P &lt; .03). The angioplasty rate was significantly lower among the tPA patients (15.0% ± 5.6) than controls (40.0% ± 8.5, P = .019). The number of days spent in severe vasospasm normalized over the 14-day monitoring period by transcranial Doppler was significantly lower in the tPA group (0.09 ± 0.02) than controls (0.17 ± 0.03). The shunt rate was significantly lower among tPA patients (17.5% ± 6.0) than controls (42.8% ± 8.6). There were 2 clinically silent tract hemorrhages in the tPA group (4.8%). CONCLUSION Intraventricular tPA is a safe and effective treatment for reducing both angioplasty and shunting rates in patients with SAH H&H Grades 3 to 5. A randomized trial is indicated.

Leukocytosis as an independent risk factor for cerebral vasospasm following aneurysmal subarachnoid hemorrhage

2003 ◽  
Vol 98 (6) ◽  
pp. 1222-1226 ◽  
Author(s):  
Matthew J. McGirt ◽  
John C. Mavropoulos ◽  
Laura Y. McGirt ◽  
Michael J. Alexander ◽  
Allan H. Friedman ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Leukocyte Count ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Content Type ◽  
Symptomatic Vasospasm ◽  
Fisher Grade ◽  
Increased Risk ◽  
Grade 3 ◽  
Fine Print

Object. The identification of patients at an increased risk for cerebral vasospasm after subarachnoid hemorrhage (SAH) may allow for more aggressive treatment and improved patient outcomes. Note, however, that blood clot size on admission remains the only factor consistently demonstrated to increase the risk of cerebral vasospasm after SAH. The goal of this study was to assess whether clinical, radiographic, or serological variables could be used to identify patients at an increased risk for cerebral vasospasm. Methods. A retrospective review was conducted in all patients with aneurysmal or spontaneous nonaneurysmal SAH who were admitted to the authors' institution between 1995 and 2001. Underlying vascular diseases (hypertension or chronic diabetes mellitus), Hunt and Hess and Fisher grades, patient age, aneurysm location, craniotomy compared with endovascular aneurysm stabilization, medications on admission, postoperative steroid agent use, and the occurrence of fever, hydrocephalus, or leukocytosis were assessed as predictors of vasospasm. Two hundred twenty-four patients were treated for SAH during the review period. One hundred one patients (45%) developed symptomatic vasospasm. Peak vasospasm occurred 5.8 ± 3 days after SAH. There were four independent predictors of vasospasm: Fisher Grade 3 SAH (odds ratio [OR] 7.5, 95% confidence interval [CI] 3.5–15.8), peak serum leukocyte count (OR 1.09, 95% CI 1.02–1.16), rupture of a posterior cerebral artery (PCA) aneurysm (OR 0.05, 95% CI 0.01–0.41), and spontaneous nonaneurysmal SAH (OR 0.14, 95% CI 0.04–0.45). A serum leukocyte count greater than 15 × 109/L was independently associated with a 3.3-fold increase in the likelihood of developing vasospasm (OR 3.33, 95% CI 1.74–6.38). Conclusions. During this 7-year period, spontaneous nonaneurysmal SAH and ruptured PCA aneurysms decreased the odds of developing vasospasm sevenfold and 20-fold, respectively. The presence of Fisher Grade 3 SAH on admission or a peak leukocyte count greater than 15 × 109/L increased the odds of vasospasm sevenfold and threefold, respectively. Monitoring of the serum leukocyte count may allow for early diagnosis and treatment of vasospasm.

Reactive Thrombocytosis in Non-aneurysmal Subarachnoid Hemorrhage

2020 ◽  
Vol 81 (05) ◽  
pp. 412-417
Author(s):  
Daniel Dubinski ◽  
Sae-Yeon Won ◽  
Bedjan Behmanesh ◽  
Nina Brawanski ◽  
Volker Seifert ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
World Federation ◽  
Reactive Thrombocytosis ◽  
Vp Shunt ◽  
Fisher Grade ◽  
The Impact

Abstract Background The role of reactive thrombocytosis in non-aneurysmal subarachnoid hemorrhage (NA-SAH) is largely unexplored to date. Therefore, the impact of a quantitative thrombocyte dynamic in patients with NA-SAH and its clinical relevance were analyzed in the present study. Methods In this retrospective analysis, 113 patients with nontraumatic and NA-SAH treated between 2003 and 2015 at our institution were included. World Federation of Neurosurgical Societies admission status, cerebral vasospasm, delayed infarction, hydrocephalus, need for ventriculoperitoneal (VP) shunt, and Fisher grade were analyzed for their association with reactive thrombocytosis. Results Reactive thrombocytosis was not associated with hydrocephalus (p ≥ 0.05), need for VP shunt implantation (p ≥ 0.05), cerebral vasospasm (p ≥ 0.05), or delayed cerebral ischemia (p ≥ 0.05). Conclusion Our study is the first to investigate the role of thrombocyte dynamics, reactive thrombocytosis, and the clinical course of NA-SAH patients. Our analysis showed no significant impact of thrombocyte count on NA-SAH sequelae.

scholarly journals P.116 Predicting cerebral vasospasm following aneurysmal subarachnoid hemorrhage is still an imperfect science

2019 ◽  
Vol 46 (s1) ◽  
pp. S44
Author(s):  
GE Pickett ◽  
MH Schmidt ◽  
JS Shankar
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Mean Transit Time ◽  
Delayed Cerebral Ischemia ◽  
Anterior Communicating Artery ◽  
Unexpected Finding ◽  
Fisher Grade

Background: Cerebral vasospasm is a leading cause of neurological disability following aneurysmal subarachnoid hemorrhage (aSAH). Clinical features associated with vasospasm development include blood burden on CT, neurological status, age and aneurysm location. Early cerebral CT perfusion (CTP) scanning in aSAH may be an independent predictor of vasospasm and/or delayed cerebral ischemia (DCI). Methods: Forty-one patients with aSAH were prospectively enrolled. Baseline data collected included WFNS grade, loss of consciousness at ictus, and modified Fisher grade. CTP was obtained at baseline and on day 6 post SAH. Cerebral blood volume, cerebral blood flow and mean transit time were measured. DCI was confirmed by a combination of clinical assessments, non-contrast CT and CTP. Radiological vasospasm was assessed with CT angiography. Results: Despite 80% of patients having a modified Fisher grade 3 or 4 aSAH, one-third presenting with ictal LOC and half having anterior communicating artery aneurysms, only one patient developed clinical evidence of vasospasm/DCI. Two others had asymptomatic radiological vasospasm. CTP parameters did not differ between groups defined by clinical predictors. Conclusions: In an unexpected finding, clinical and radiological vasospasm were very uncommon in this cohort. Clinical predictive variables correlated poorly with development of vasospasm. CTP may help refine the model but further work is needed.

scholarly journals Cerebral Vasospasm with Ischemia following a Spontaneous Spinal Subarachnoid Hemorrhage

2013 ◽  
Vol 2013 ◽  
pp. 1-5 ◽  
Author(s):  
Sophia F. Shakur ◽  
Hamad I. Farhat
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
Brain Mri ◽  
International Normalized Ratio ◽  
Unique Case ◽  
First Case ◽  
Spinal Subarachnoid Hemorrhage ◽  
Spine Mri

Cerebral vasospasm is a well-known consequence of aneurysmal subarachnoid hemorrhage (SAH) triggered by blood breakdown products. Here, we present the first case of cerebral vasospasm with ischemia following a spontaneous spinal SAH. A 67-year-old woman, who was on Coumadin for atrial fibrillation, presented with chest pain radiating to the back accompanied by headache and leg paresthesias. The international normalized ratio (INR) was 4.5. Ten hours after presentation, she developed loss of movement in both legs and lack of sensation below the umbilicus. Spine MRI showed intradural hemorrhage. Her coagulopathy was reversed, and she underwent T2 to T12 laminectomies. A large subarachnoid hematoma was evacuated. Given her complaint of headache preoperatively and the intraoperative finding of spinal SAH, a head CT was done postoperatively that displayed SAH in peripheral sulci. On postoperative day 5, she became obtunded. Brain MRI demonstrated focal restricted diffusion in the left frontoparietal area. Formal angiography revealed vasospasm in anterior cerebral arteries bilaterally and right middle cerebral artery. Vasospasm was treated, and she returned to baseline within 48 hours. Spontaneous spinal SAH can result in the same sequelae typically associated with aneurysmal SAH, and the clinician must have a degree of suspicion in such patients. The pathophysiological mechanisms underlying cerebral vasospasm may explain this unique case.

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms

2017 ◽  
Vol 14 (3) ◽  
pp. 231-235 ◽  
Author(s):  
Roland Roelz ◽  
Christian Scheiwe ◽  
Horst Urbach ◽  
Volker A Coenen ◽  
Peter Reinacher
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Blood Clearance ◽  
Fisher Grade ◽  
Rapid Clearance ◽  
Promising Treatment ◽  
Grade 3 ◽  
Subarachnoid Blood ◽  
The Brain

Abstract BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.

Sign in / Sign up

Export Citation Format

Share Document