DISCLOSURES<br />BASED ON EARLY CONSULTATION WITH COMPANY ON DESIGN OF TECHNOLOGY RECEIVED A MINOR STOCK POSITION WITH NEU...
WHAT IS THE ICU STAFF <br />ASKING THEMSELVES??<br />WHAT DID WE DO WITHOUT <br />A PORTABLE SCANNER? <br />
MULTIPLE TRAUMA WITH SEVERE TBI<br />PHYSIOLOGICALLY UNSTABLE WITH <br />ALL THE MONITORS WE KNOW HOW TO PLACE.  VENTILATI...
BRING HE TECHNOLOGY TO THE PATIENT… <br />DO NOT HAVE TO BE A “ROCKET SCIENTIST ” TO FIGURE THIS OUT….  <br />
PAST BARRIERS<br />TOMO M (PHILLIPS) -- 1990’S<br />TOO LARGE, TOO HEAVY, TOO UNRELIABLE, TOO DIFFICULT TO USE.<br />CERET...
WHY DO WE NEED A PORTABLE SCANNER?<br />BECAUSE MOVEMENT OF MARGINALLY STABLE ICU PATIENTS OUT OF THE UNIT IS DANGEROUS	<b...
WHY A PORTABLE SCANNER <br />BETTER FOR THE PATIENT<br />BETTER FOR OTHER PATIENTS<br />BETTER FOR STAFF (NURSING, INHALAT...
WHY NOT <br />IMAGING NOT EQUAL TO FIXED BASED SCANNERS<br />IF NOT EQUAL….VERY CLOSE<br />NOT ENOUGH TECHNICAL SUPPORT<br...
Head Computed Tomography Scanner Technology and Applications: Experience with 3421 Scans<br />Andrew P. Carlson, MD, Howar...
RESULTS<br />Between June of 2006 and December of 2009, a total of 3421 portable CTs were performed.<br />A total of 3278 ...
-STORED IN HALL<br />-BATTERY POWERED<br />-CHARGE MAINTAINED <br />WITH 120 V WALL PLUG<br />-ONE AVERAGE TECH <br />CAN ...
2.5 FEET<br />
Scattered Radiation Diagram<br />
CERETOM CT (Non Enhanced)<br />Acquisition method<br />Axial<br />Acquired in 1.25mm slices<br />Reconstruction<br />On th...
Image Comparison<br />Portable CT image<br />Fixed CT image<br />Same patient scanned 24 hours apart on the CereTom and fi...
Comparison:  Coronal Sinus Images<br />4 months apart, Same Patient, Same Dose, Same recon settings<br />CereTom<br />GE L...
Various CERETOM Scans<br />
CERETOM GOES ELSEWHERE<br />OPERATING ROOM <br />PLACEMENT OF VENTRICULAR CATHETERS<br />EXTENT OF TUMOR REMOVAL– <br />MO...
REMOVE RETRACTOR SYSTEM AND ALL METAL OVER HEAD. <br />10-15 MINUTES FROM START TO REVIEW OF IMAGES.<br />Intra Operative ...
DESPITE <br />NAVIGATION<br />TARGETS CAN <br />MOVE DUE TO <br />FIRM CAPSULE<br />
TUMORS CAN HIDE<br />
REMAINING AVM CAN HIDE ---<br />(DIFFICULT TO DO INTRA OPERATIVE ANGIO IN <br />PRONE POSITION)<br />
PEDIATRIC ICU<br />SINGLE ROTATION OF SCANNER CAN IMAGE WITH VERY LOW RADIATION EXPOSURE<br />
XENON/CT CBF INTEGRATED WITHIN CERETOM<br />WHY HAVE WE CONTINUED TO PURSUE?<br />ONLY MEANS OF OBTAINING QUANTITATIVE CBF...
BEEN AT THIS FOR A LONG <br />TIME   (1978---)<br />⏎<br />-REBREATHER-  8 LITERS XE/STUDY<br />-CALCULATION IN 10 SECOND...
2009 A NEW XE/CT CBF <br />-INTEGRATED WITH CERETOM <br />-CALCULATION 10 SECONDS <br />   IMMEDIATE DISPLAY<br />-REBREAT...
WHY PERSIST??   BECAUSE REAL TOMOGRPAHIC HIGH RESOLUTION CBF IS IMPORTANT!<br />PROBABILITY OF INFARCTION<br />20     40  ...
INFARCTED TISSUE (CORE)  IS TISSUE WITH <br />< 9 CC/100GMS/MIN : <br /><ul><li>STRONGLY PREDICTIVE OF SYMPTOMATIC  HEMORR...
ENDOVASCULAR REPERFUSION ASSOCIATED WITH HEMORRHAGIC 	COMPLICATION.                                                     GU...
NEED REAL NUMBERS TO DECIDE ON VESSEL SACIFICEALL QUALITATIVE METHODS FAIL 50% OF TIME..<br />
BASELINE<br />BTO<br />CAROTID <br />OCCLUSION+<br />BYPASS<br />
WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA..<br />CT  DA...
WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA..<br />CT    ...
WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA.<br />CBF DAT...
TEST RE TEST<br />XE/CT CBF ALLOWS FOR A RAPID AND DIRECT MEASUREMENT OF RESULT OF PHYSIOLOGICAL CHANGE.<br />SHOULD WE RA...
5 DAYS POST ICA ANEURYSM RUPTURE, NEW LEFT HEMIPARESIS DESPITE BLOOD PRESSURE ELEVATION TO  170 MMHG SYSTOLIC STILL HEMIPA...
RAISING PRESSURE FURTHER ELEVATED CBF AND CLEARED DEFICITS.<br />NO LONGER ISCHEMIC.  NOW WHAT?  ANGIOPLASTY<br />220/125 ...
DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM,  ON PRESSORS. WHEN TO WITHDRAW PRESSORS?<br />168/90 ON NEO ...
DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM,  ON PRESSORS.<br />WHEN TO WITHDRAW PRESSORS?<br />168/90 ON...
INTRACEREBRAL BLEED 24  YEAR OLD WOMAN POST PARTUM<br />170 MMHG<br />WE THINK WE <br />KNOW: <br />BP TOO HIGH,<br />MUST...
TOO LOW?<br />175 mm Hg<br />140 mm Hg<br />1 CM ABOVE           L Basal Ganglia ICH<br />LEVEL 4<br />             GLOBAL...
WHAT ABOUTLOWERING  CO2 TO IMPROVE ICP??IS THERE A FLOOR??<br />
GSW- 18 YEAR OLD, GCS 8<br />PCO2 38MMHG AND  ICP 35 MMGG.<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br />BASELI...
GSW- 18 YEAR OLD,  ICP 35 MMGG.<br />HOW LOW CAN YOU GO WITH CO2?<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br /...
GSW- 18 YEAR OLD , ICP25 MMHG WITH <br />PCO2 OF 27 MMHG,<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br />pCO2 = ...
HEAD TRAUMA 12 YEAR OLD, GCS 7 <br />ICP 35 MMHG.PCO2 36 MMHG.  <br />LEVEL 1<br />LEVEL 2<br />LEVEL 3<br />LEVEL 4<br />...
HEAD TRAUMA 12 YEAR OLD, GCS 7 <br />ICP 35 MMHG, PCO2 36 MMGH<br />LEVEL 1<br />LEVEL 2<br />LEVEL 3<br />LEVEL 4<br />BA...
HEAD TRAUMA 12 YEAR OLD, GCS 7                                 CO2 24 AND ICP 18 MMGH.<br />WHAT IS OUR GOAL, ICP, CPP, PC...
CAN AN INITIAL XENON/CT CBF STUDY OBTAINED EARLY AFTER SEVERE TBI PREDICT OUTCOME? <br />NIH GRANT PI:      <br />CLAUDIA ...
TN= VOLUME CORTICAL<br />   MANTLE WITH FLOW <br />   > 30 CC/100GMS/MIN<br />TC+P= VOLUME <br />  CORTICAL MANTLE <br /> ...
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Yonas, Howard

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Yonas, Howard

  1. 1. DISCLOSURES<br />BASED ON EARLY CONSULTATION WITH COMPANY ON DESIGN OF TECHNOLOGY RECEIVED A MINOR STOCK POSITION WITH NEUROLOGICA INC, MAKER OF CERETOM.<br />XENON/CT CBF NOT FDA APPROVED.. XENON/CT CBF INTEGRATED WITHIN CERETM SCANNER BUT AVAILABLE ONLY UNDER AN INVESTIGATIVE PROTOCOL…<br />REAPPROACHING FDA IN 2011… <br />
  2. 2. WHAT IS THE ICU STAFF <br />ASKING THEMSELVES??<br />WHAT DID WE DO WITHOUT <br />A PORTABLE SCANNER? <br />
  3. 3. MULTIPLE TRAUMA WITH SEVERE TBI<br />PHYSIOLOGICALLY UNSTABLE WITH <br />ALL THE MONITORS WE KNOW HOW TO PLACE. VENTILATION STATUS MARGINAL…. <br />THIS IS SOMEONE WE DO NOT WANT TO SEE TAKING A “ROAD TRIP”.. <br />WE WERE FORCED TO PROVIDE CARE WITHOUT VITAL ANATOMIC AND PHYSIOLOGICAL DATA<br />
  4. 4. BRING HE TECHNOLOGY TO THE PATIENT… <br />DO NOT HAVE TO BE A “ROCKET SCIENTIST ” TO FIGURE THIS OUT…. <br />
  5. 5. PAST BARRIERS<br />TOMO M (PHILLIPS) -- 1990’S<br />TOO LARGE, TOO HEAVY, TOO UNRELIABLE, TOO DIFFICULT TO USE.<br />CERETOM (NEUROLOGICA)-- 2004+<br />SMALLER,<br />LIGHTER, <br />MORE RELIABLE, <br />USER FRIENDLY<br />
  6. 6. WHY DO WE NEED A PORTABLE SCANNER?<br />BECAUSE MOVEMENT OF MARGINALLY STABLE ICU PATIENTS OUT OF THE UNIT IS DANGEROUS <br />25% OF HIGH RISK PATIENTS HAVE A COMPLICATION DUE TO TRANSPORT..<br />COMPROMISES CARE OF PATIENTS REMAINING IN UNIT<br />REDUCES PRODUCTIVITY OF LARGER FIXED SCANNERS <br />
  7. 7. WHY A PORTABLE SCANNER <br />BETTER FOR THE PATIENT<br />BETTER FOR OTHER PATIENTS<br />BETTER FOR STAFF (NURSING, INHALATION THERAPY AND MEDICAL)<br />BETTER FOR HOSPITAL <br />LOW COST OF ACQUISITION (1/3 COST OF FIXED SCANNER)<br />
  8. 8. WHY NOT <br />IMAGING NOT EQUAL TO FIXED BASED SCANNERS<br />IF NOT EQUAL….VERY CLOSE<br />NOT ENOUGH TECHNICAL SUPPORT<br />MAY NEED MORE CT TECH SUPPORT<br />PERCEIVED LOSS OF CONTROL OF IMAGING TECHNOLOGY BY RADIOLOGY<br />UNIQUE TO EACH HOSPITAL<br />
  9. 9. Head Computed Tomography Scanner Technology and Applications: Experience with 3421 Scans<br />Andrew P. Carlson, MD, Howard Yonas, MD<br />From the Department of Neurosurgery, University of New Mexico, Albuquerque, NM.<br />METHODS<br />We describe the clinical use of a portable head CT scanner (CereTom: NeuroLogica: Danvers, MA) that can be brought to the patient’s bedside or to other locations such as the operating room or angiography suite.<br />
  10. 10. RESULTS<br />Between June of 2006 and December of 2009, a total of 3421 portable CTs were performed.<br />A total of 3278 (95.8%) were performed in the neuroscience intensive care unit (ICU) for an average of 2.6 neuroscience ICU CT scans per day. Other locations where CTs were performed included other ICUs (n = 97), the operating room (n = 53), the emergency department (n = 1), and the angiography suite (n = 2). Most studies were non-contrasted<br />head CT, though other modalities including xenon/CT, contrasted CT, and CT angiography were performed.<br />CONCLUSION<br />Portable head CT can reliably and consistently be performed at the patient’s bedside. This should lead to decreased transportation-related morbidity and improved rapid decision making in the ICU, OR, and other locations. <br />
  11. 11. -STORED IN HALL<br />-BATTERY POWERED<br />-CHARGE MAINTAINED <br />WITH 120 V WALL PLUG<br />-ONE AVERAGE TECH <br />CAN ROLE TO PATIENT<br />-PATIENT HEAD IS STILL AND <br /> SCANNER MOVES <br />
  12. 12. 2.5 FEET<br />
  13. 13.
  14. 14. Scattered Radiation Diagram<br />
  15. 15. CERETOM CT (Non Enhanced)<br />Acquisition method<br />Axial<br />Acquired in 1.25mm slices<br />Reconstruction<br />On the scanner<br />In real time<br />1.25mm, 2.5mm, 5mm & 10mm<br />DICOM<br />SOFT WARE IMPROVEMENTS HAVE <br />STEADILY IMPROVED IMAGE <br />QUALITY..<br />
  16. 16. Image Comparison<br />Portable CT image<br />Fixed CT image<br />Same patient scanned 24 hours apart on the CereTom and fixed scanner<br />
  17. 17. Comparison: Coronal Sinus Images<br />4 months apart, Same Patient, Same Dose, Same recon settings<br />CereTom<br />GE Lightspeed<br />
  18. 18. Various CERETOM Scans<br />
  19. 19. CERETOM GOES ELSEWHERE<br />OPERATING ROOM <br />PLACEMENT OF VENTRICULAR CATHETERS<br />EXTENT OF TUMOR REMOVAL– <br />MOST TUMORS ARE EVIDENT WITH CONTRAST<br />PEDIATRIC ICU<br />ANGIO SUITE<br />EVALUATE HEMORRHAGE<br />CBF <br />
  20. 20. REMOVE RETRACTOR SYSTEM AND ALL METAL OVER HEAD. <br />10-15 MINUTES FROM START TO REVIEW OF IMAGES.<br />Intra Operative Scanning<br />
  21. 21. DESPITE <br />NAVIGATION<br />TARGETS CAN <br />MOVE DUE TO <br />FIRM CAPSULE<br />
  22. 22. TUMORS CAN HIDE<br />
  23. 23. REMAINING AVM CAN HIDE ---<br />(DIFFICULT TO DO INTRA OPERATIVE ANGIO IN <br />PRONE POSITION)<br />
  24. 24. PEDIATRIC ICU<br />SINGLE ROTATION OF SCANNER CAN IMAGE WITH VERY LOW RADIATION EXPOSURE<br />
  25. 25. XENON/CT CBF INTEGRATED WITHIN CERETOM<br />WHY HAVE WE CONTINUED TO PURSUE?<br />ONLY MEANS OF OBTAINING QUANTITATIVE CBF AT BEDSIDE. <br />24,000 CALCULATIONS PER CT IMAGE X 4 IMAGES<br />SAFEST CONTRAST AGENT WITH VERY RAPID WASHIN AND WASHOUT<br />STUDIES REPEATABLE WITHIN 10 MINUTES<br />
  26. 26. BEEN AT THIS FOR A LONG <br />TIME (1978---)<br />⏎<br />-REBREATHER- 8 LITERS XE/STUDY<br />-CALCULATION IN 10 SECONDS<br /> SEPARATE COMPUTER <br />---------I HAD SOME HAIR<br />-33% XENON FILLED BAG <br /> 20 LITERS/STUDY<br />-GE SCANNER INTEGRATION<br />-CALCULALTION 1 HOUR PER <br />LEVEL <br />------I HAD LOTS OF HAIR<br />
  27. 27. 2009 A NEW XE/CT CBF <br />-INTEGRATED WITH CERETOM <br />-CALCULATION 10 SECONDS <br /> IMMEDIATE DISPLAY<br />-REBREATHER (8 LITERS 23% XENON/STUDY)<br />---- I HAVE MUCH LESS HAIR <br />FINALLY:<br />-RIGHT PLACE<br />-RIGHT TIMING<br />-WITH THE <br /> RIGHT STUFF<br />
  28. 28. WHY PERSIST?? BECAUSE REAL TOMOGRPAHIC HIGH RESOLUTION CBF IS IMPORTANT!<br />PROBABILITY OF INFARCTION<br />20 40 cc/100gms/min<br />JOVIN, STROKE 03<br />
  29. 29. INFARCTED TISSUE (CORE) IS TISSUE WITH <br />< 9 CC/100GMS/MIN : <br /><ul><li>STRONGLY PREDICTIVE OF SYMPTOMATIC HEMORRHAGE WITH REPERFUSION. FIRLIK, 1999
  30. 30. ENDOVASCULAR REPERFUSION ASSOCIATED WITH HEMORRHAGIC COMPLICATION. GUPTA, 2006</li></ul> HERNIATION IF INVOLVES MOST OF MCA. FIRLIK, 1999<br />FAILED REPERFUSION<br />HOUR 48<br />HOUR 2<br />HOUR 24<br />
  31. 31. NEED REAL NUMBERS TO DECIDE ON VESSEL SACIFICEALL QUALITATIVE METHODS FAIL 50% OF TIME..<br />
  32. 32. BASELINE<br />BTO<br />CAROTID <br />OCCLUSION+<br />BYPASS<br />
  33. 33. WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA..<br />CT DAY 1<br />
  34. 34. WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA..<br />CT DAY 1 CBF<br />
  35. 35. WHY TOMOGRAPHIC DATA<br />BECAUSE INJURY IS RARELY HOMOGENEOUS, <br />ESPECIALLY IN THE WORLD OF HEAD TRAUMA.<br />CBF DATA CAN TELL YOU WHERE TO PLACE PROBE<br />AND IMPORTANTLY, HOW TO INTERPRET <br />..<br />CT DAY ONE CBF<br />CT DAY 2<br />LICOX <br />PROBE<br />
  36. 36. TEST RE TEST<br />XE/CT CBF ALLOWS FOR A RAPID AND DIRECT MEASUREMENT OF RESULT OF PHYSIOLOGICAL CHANGE.<br />SHOULD WE RAISE OR LOWER THE BLOOD PRESSURE??<br />
  37. 37. 5 DAYS POST ICA ANEURYSM RUPTURE, NEW LEFT HEMIPARESIS DESPITE BLOOD PRESSURE ELEVATION TO 170 MMHG SYSTOLIC STILL HEMIPARETIC, APHASIC AND ISCHEMIC <br />MCA FLOW<br />18 CC/100GMS/MIN<br />170/110 on Dopamine<br />SHOULD BP BE HIGHER AND IF SO HOW HIGH??<br />
  38. 38. RAISING PRESSURE FURTHER ELEVATED CBF AND CLEARED DEFICITS.<br />NO LONGER ISCHEMIC. NOW WHAT? ANGIOPLASTY<br />220/125 on more Dopamine<br />170/110 on<br />Dopamine<br />QUANTITATIVE INFORMATION PROVIDES NEEDED GUIDANCE<br />
  39. 39. DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM, ON PRESSORS. WHEN TO WITHDRAW PRESSORS?<br />168/90 ON NEO 145/80 OFF NEO<br /> ?<br />
  40. 40. DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM, ON PRESSORS.<br />WHEN TO WITHDRAW PRESSORS?<br />168/90 ON NEO 145/80 OFF NEO<br />TOO SOON!!!!!<br />
  41. 41. INTRACEREBRAL BLEED 24 YEAR OLD WOMAN POST PARTUM<br />170 MMHG<br />WE THINK WE <br />KNOW: <br />BP TOO HIGH,<br />MUST LOWER<br />BLUE < 20 CC/100GMS/MIN<br />LAVENDER<br /> <8 CC/100GMS/MIN<br />LEVEL BELOW<br />
  42. 42. TOO LOW?<br />175 mm Hg<br />140 mm Hg<br />1 CM ABOVE L Basal Ganglia ICH<br />LEVEL 4<br /> GLOBAL REDUCTION OF FLOW WITH FOCAL INCREASE OF CORE AND PENUMBRA <br />1 CM BELOW<br />
  43. 43. WHAT ABOUTLOWERING CO2 TO IMPROVE ICP??IS THERE A FLOOR??<br />
  44. 44. GSW- 18 YEAR OLD, GCS 8<br />PCO2 38MMHG AND ICP 35 MMGG.<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br />BASELINE CT<br />pCO2 = 38<br />
  45. 45. GSW- 18 YEAR OLD, ICP 35 MMGG.<br />HOW LOW CAN YOU GO WITH CO2?<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br />BASELINE CT<br />pCO2 = 38<br />FLOW LOOKS “NORMAL” DESPITE HIGH ICP<br />
  46. 46. GSW- 18 YEAR OLD , ICP25 MMHG WITH <br />PCO2 OF 27 MMHG,<br />Level 4<br />Level 1<br />Level 2<br />Level 3<br />pCO2 = 38<br />pCO2 = 27<br />IMPROVED ICP BUT MADE BRAIN ISCHEMIC,<br />WHAT IS THE GOAL?<br />
  47. 47. HEAD TRAUMA 12 YEAR OLD, GCS 7 <br />ICP 35 MMHG.PCO2 36 MMHG. <br />LEVEL 1<br />LEVEL 2<br />LEVEL 3<br />LEVEL 4<br />BASELINE<br />pCO2 = 36<br />
  48. 48. HEAD TRAUMA 12 YEAR OLD, GCS 7 <br />ICP 35 MMHG, PCO2 36 MMGH<br />LEVEL 1<br />LEVEL 2<br />LEVEL 3<br />LEVEL 4<br />BASELINE<br />pCO2 = 36<br />CBF 70 CC/100GMS/MIN WITH LOW GCS, <br />CLEARLY HYPEREMIC. HOW LOW SHOULD PCO2 GO??<br />
  49. 49. HEAD TRAUMA 12 YEAR OLD, GCS 7 CO2 24 AND ICP 18 MMGH.<br />WHAT IS OUR GOAL, ICP, CPP, PCO2 OR CBF???<br />LEVEL 1<br />LEVEL 2<br />LEVEL 3<br />LEVEL 4<br />BASELINE<br />pCO2 = 36<br />pCO2 = <br />24 mmHg<br />NEED PATIENT SPECIFIC INFORMATION. LUMPING IS EASIER BUT <br />UNDERSTANDING EACH PATIENT HAS TO BE THE GOAL.<br />
  50. 50. CAN AN INITIAL XENON/CT CBF STUDY OBTAINED EARLY AFTER SEVERE TBI PREDICT OUTCOME? <br />NIH GRANT PI: <br />CLAUDIA ROBERTSON<br />DAY ONEXENON/CT CBF STUDIES OBTAINED AND OUTCOMES ASSESSED AS PART OF A PROSPECTIVE TBI DRUG TRIAL..<br />RE ANALYSIS BY ED NEMOTO <br />
  51. 51. TN= VOLUME CORTICAL<br /> MANTLE WITH FLOW <br /> > 30 CC/100GMS/MIN<br />TC+P= VOLUME <br /> CORTICAL MANTLE <br /> < 30 CC/100GMS/MIN<br />DAY ONE FLOW VALUES<br />PREDICT OUT COME AT<br />ONE AND 6 MONTHS<br />I MO GOS<br />6 MO GOS<br />
  52. 52. THE GOAL HAS TO BE BRINGING THE TECHNOLOGY TO THE PATIENT WITH BOTH FOCAL AND GLOBAL, EPISODIC AND CONTINUOUS <br />MONITORS OF VITAL VARIABLES. <br />QUANTITATIVE TOMOGRAPHIC CBF SHOULD BE PART OF THE GOAL…<br />THANK YOU FOR ALLOWING <br />ME TO SHARE SOME OF OUR <br />EXPERIENCE AT THE <br />UNIVERSITY OF NEW<br />MEXICO.. <br />

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