Neeraj Badjatia

University of Maryland, Baltimore, Baltimore, Maryland, United States

Are you Neeraj Badjatia?

Claim your profile

Publications (222)755.65 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH). This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥4 and assessed by multivariable logistic regression. There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04). Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH. © 2015 American Academy of Neurology.
    Neurology 01/2015; 84(7). DOI:10.1212/WNL.0000000000001259 · 8.30 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Careful patient monitoring using a variety of techniques including clinical and laboratory evaluation, bedside physiological monitoring with continuous or non-continuous techniques and imaging is fundamental to the care of patients who require neurocritical care. How best to perform and use bedside monitoring is still being elucidated. To create a basic platform for care and a foundation for further research the Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to develop recommendations about physiologic bedside monitoring. This supplement contains a Consensus Summary Statement with recommendations and individual topic reviews as a background to the recommendations. In this article, we highlight the recommendations and provide additional conclusions as an aid to the reader and to facilitate bedside care.
    Neurocritical Care 12/2014; 21(S2). DOI:10.1007/s12028-014-0077-6 · 2.60 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: It is common for patients who die from subarachnoid hemorrhage to have a focus on comfort measures at the end of life. The potential role of ethnicity in end-of-life decisions after brain injury has not been extensively studied. Patients with subarachnoid hemorrhage were prospectively followed in an observational database. Demographic information including ethnicity was collected from medical records and self-reported by patients or their family. Significant in-hospital events including do-not-resuscitate orders, comfort measures only orders (CMO; care withheld or withdrawn), and mortality were recorded prospectively. 1255 patients were included in our analysis: 650 (52 %) were White, 387 (31 %) Hispanic, and 218 (17 %) Black. Mortality was similar between the groups. CMO was more commonly observed in Whites (14 %) compared to either Blacks (10 %) or Hispanics (9 %) (p = 0.04). In a multivariate analysis controlling for age and Hunt-Hess grade, Hispanics were less likely to have CMO than Whites (OR, 0.6; 95 %CI, 0.4-0.9; p = 0.02). Of the 229 patients who died, 77 % of Whites had CMO compared to 54 % of Blacks and 49 % of Hispanics (p < 0.01). In a multivariate analysis, Blacks (OR, 0.3; 95 %CI, 0.2-0.7; p < 0.01) and Hispanics (OR, 0.3; 95 %CI, 0.2-0.6; p < 0.01) were less likely to die with CMO orders than Whites. After subarachnoid hemorrhage, Blacks and Hispanics are less likely to die with CMO orders than Whites. Further research to confirm and investigate the causes of these ethnic differences should be performed.
    Neurocritical Care 12/2014; 22(3). DOI:10.1007/s12028-014-0073-x · 2.60 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants’ collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.
    Neurocritical Care 12/2014; 21(S2):1-26. DOI:10.1007/s12028-014-0041-5 · 2.60 Impact Factor
  • J Javier Provencio, Neeraj Badjatia
    [Show abstract] [Hide abstract]
    ABSTRACT: Inflammation is an important part of the normal physiologic response to acute brain injury (ABI). How inflammation is manifest determines if it augments or hinders the resolution of ABI. Monitoring body temperature, the cellular arm of the inflammatory cascade, and inflammatory proteins may help guide therapy. This summary will address the utility of inflammation monitoring in brain-injured adults. An electronic literature search was conducted for English language articles describing the testing, utility, and optimal methods to measure inflammation in ABI. Ninety-four articles were included in this review. Current evidence suggests that control of inflammation after ABI may hold promise for advances in good outcomes. However, our understanding of how much inflammation is good and how much is deleterious is not yet clear. Several important concepts emerge form our review. First, while continuous temperature monitoring of core body temperature is recommended, temperature pattern alone is not useful in distinguishing infectious from noninfectious fever. Second, when targeted temperature management is used, shivering should be monitored at least hourly. Finally, white blood cell levels and protein markers of inflammation may have a limited role in distinguishing infectious from noninfectious fever. Our understanding of optimal use of inflammation monitoring after ABI is limited currently but is an area of active investigation.
    Neurocritical Care 10/2014; 21(S2). DOI:10.1007/s12028-014-0038-0 · 2.60 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Risk factors for infections after intracerebral hemorrhage (ICH) and their association with outcomes are unknown. We hypothesized there are predictors of poststroke infection and infections drive worse outcomes.
    Stroke 10/2014; 45(12). DOI:10.1161/STROKEAHA.114.006435 · 6.02 Impact Factor
  • Neeraj Badjatia, Paul Vespa
    [Show abstract] [Hide abstract]
    ABSTRACT: The metabolic response to injury is well described; however, very little is understood about optimal markers to measure this response. This summary will address the current evidence about monitoring nutritional status including blood glucose after acute brain injury (ABI). An electronic literature search was conducted for English language articles describing the testing, utility, and optimal methods to measure nutritional status and blood glucose levels in the neurocritical care population. A total of 45 articles were included in this review. Providing adequate and timely nutritional support can help improve outcome after ABI. However, the optimal content and total nutrition requirements remain unclear. In addition, how best to monitor the nutritional status in ABI is still being elucidated, and at present, there is no validated optimal method to monitor the global response to nutritional support on a day-to-day basis in ABI patients. Nitrogen balance may be monitored to assess the adequacy of caloric intake as it relates to protein energy metabolism, but indirect calorimetry, anthropometric measurement, or serum biomarker requires further validation. The adverse effects of hyperglycemia in ABI are well described, and data indicate that blood glucose should be carefully controlled in critically ill patients. However, the optimal frequency or duration for blood glucose monitoring after ABI remains poorly defined. There are significant knowledge gaps about monitoring nutritional status and response to nutritional interventions in ABI; these need to be addressed and hence few recommendations can be made. The optimal frequency and duration of blood glucose monitoring need further study.
    Neurocritical Care 09/2014; 21(S2). DOI:10.1007/s12028-014-0036-2 · 2.60 Impact Factor
  • Article: Neurotrauma
    Wan-Tsu W. Chang, Neeraj Badjatia
    [Show abstract] [Hide abstract]
    ABSTRACT: Neurotrauma continues to be a significant cause of morbidity and mortality. Prevention of primary neurologic injury is a critical public health concern. Early and thorough assessment of the patient with neurotrauma with high index of suspicion of traumatic spinal cord injuries and traumatic vascular injuries requires a multidisciplinary approach involving prehospital providers, emergency physicians, neurosurgeons, and neurointensivists. Critical care management of the patient with neurotrauma is focused on the prevention of secondary injuries. Much research is still needed for potential neuroprotection therapies. Copyright © 2014 Elsevier Inc. All rights reserved.
    Emergency Medicine Clinics of North America 09/2014; DOI:10.1016/j.emc.2014.07.008 · 0.85 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.
    Intensive Care Medicine 08/2014; 40(9). DOI:10.1007/s00134-014-3369-6 · 5.54 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Fibrocartilaginous embolism (FCE) is an uncommon cause of myelopathy that should be considered after more common causes have been ruled out.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective To determine the association between exposure to hyperoxia and the risk of delayed cerebral ischaemia (DCI) after subarachnoid haemorrhage (SAH). Methods We analysed data from a single centre, prospective, observational cohort database. Patient inclusion criteria were age >= 18 years, aneurysmal SAH, endotracheal intubation with mechanical ventilation, and arterial partial pressure of oxygen (PaO2) measurements. Hyperoxia was defined as the highest quartile of an area under the curve of PaO2, until the development of DCI (PaO2 >= 173 mm Hg). Poor outcome was defined as modified Rankin Scale 4-6 at 3 months after SAH. Results Of 252 patients, there were no differences in baseline characteristics between the hyperoxia and control group. Ninety-seven (38.5%) patients developed DCI. The hyperoxia group had a higher incidence of DCI (p<0.001) and poor outcome (p=0.087). After adjusting for modified Fisher scale, rebleeding, global cerebral oedema, intracranial pressure crisis, pneumonia and sepsis, hyperoxia was independently associated with DCI (OR, 3.16; 95% CI 1.69 to 5.92; p<0.001). After adjusting for age, Hunt-Hess grade, aneurysm size, Acute Physiology and Chronic Health Evaluation II score, rebleeding, pneumonia and sepsis, hyperoxia was independently associated with poor outcome (OR, 2.30; 95% CI 1.03 to 5.12; p=0.042). Conclusions In SAH patients, exposure to hyperoxia was associated with DCI. Our findings suggest that exposure to excess oxygen after SAH may represent a modifiable factor for morbidity and mortality in this population.
    Journal of Neurology Neurosurgery & Psychiatry 05/2014; 85(12). DOI:10.1136/jnnp-2013-307314 · 5.58 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage. Methods A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. Results Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03). Conclusions Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage.
    Critical care (London, England) 05/2014; 18(3):R89. DOI:10.1186/cc13857
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Nonconvulsive seizures (NCSz) are frequent following acute brain injury and have been implicated as a cause of secondary brain injury but mechanisms that cause NCSz are controversial. Pro-inflammatory states are common after many brain injuries and inflammatory mediated changes in blood-brain-barrier permeability have experimentally been linked to seizures.Methods: In this prospective observational study of aneurysmal subarachnoid hemorrhage (SAH) patients we explored the link between the inflammatory response following SAH and in-hospital NCSz studying clinical (systemic inflammatory response syndrome,SIRS) and laboratory markers of inflammation (tumor necrosis factor receptor 1,TNF-R1; high sensitivity C-reactive protein,hsCRP). Logistic regression, cox proportional hazards regression, and mediation analyses were performed to investigate temporal and causal relationships.Results: Among 479 SAH patients, 53(11%) had in-hospital NCSz. Patients with in-hospital NCSz had a more pronounced SIRS response (OR1.9 per point increase in SIRS; 95%-CI1.3-2.9), inflammatory surges were more likely immediately preceding NCSz onset, and the negative impact of SIRS on functional outcome at 3 months was mediated in part through in-hospital NCSz. In a subset with inflammatory serum biomarkers we confirmed these findings linking higher serum TNF-R1 and hsCRP to in-hospital NCSz (OR1.2 per 20 point hsCRP increase [95%-CI1.1-1.4]; OR2.5 per 100 point TNF-R1 increase [95%-CI2.1-2.9]). The association of inflammatory biomarkers with poor outcome was mediated in part through NCSz.Interpretation: In-hospital NCSz were independently associated with a pro-inflammatory state following SAH reflected in clinical symptoms and serum biomarkers of inflammation. Our findings suggest that inflammation following SAH is associated with poor outcome and this effect is at least in part mediated through in-hospital NCSz. ANN NEUROL 2014. © 2014 American Neurological Association
    Annals of Neurology 05/2014; 75(5). DOI:10.1002/ana.24166 · 11.91 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: We sought to determine whether therapeutic temperature modulation (TTM) to treat fever after intracerebral hemorrhage (ICH) is associated with improved hospital complications and discharge outcomes. We performed a retrospective case-control study of patients admitted with spontaneous ICH having two consecutive fevers ≥38.3 °C despite acetaminophen administration. Cases were enrolled from a prospective database of patients receiving TTM from 2006 to 2010. All cases received TTM for fever control with goal temperature of 37 °C with a shiver-control protocol. Controls were matched in severity by ICH score and retrospectively obtained from 2001 to 2004, before routine use of TTM for ICH. Primary outcome was discharge-modified Rankin score. Forty patients were enrolled in each group. Median admission ICH Score, ICH volume, and GCS were similar. TTM was initiated with a median of 3 days after ICH onset and for a median duration of 7 days. Mean daily T max was significantly higher in the control group over the first 12 days (38.1 vs. 38.7 °C, p ≤ 0.001). The TTM group had more days of IV sedation (median 8 vs. 1, p < 0.001) and mechanical ventilation (18 vs. 9, p = 0.003), and more frequently underwent tracheostomy (55 vs. 23 %, p = 0.005). Mean NICU length of stay was longer for TTM patients (15 vs. 11 days, p = 0.007). There was no difference in discharge outcomes between the two groups (overall mortality 33 %, moderate or severe disability 67 %). Therapeutic normothermia is associated with increased duration of sedation, mechanical ventilation, and NICU stay, but is not clearly associated with improved discharge outcome.
    Neurocritical Care 01/2014; 21(2). DOI:10.1007/s12028-013-9948-5 · 2.60 Impact Factor
  • World Neurosurgery 11/2013; 80(5):670. DOI:10.1016/j.wneu.2013.07.063 · 2.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cerebral microbleeds (CMBs) are commonly found after stroke, but have not been previously studied in patients with subarachnoid hemorrhage (SAH). To study the prevalence, radiographic patterns, predictors, and impact on outcome of CMBs in patients with SAH. We analyzed retrospectively 39 consecutive patients who underwent T2-weighted gradient-echo imaging within seven days after onset of spontaneous SAH. We report frequency and location of CMBs and show their association with demographics, vascular risk factors, the Hunt-Hess grade, the modified Fisher Scale, the Acute Physiologic and Chronic Health Evaluation II, MRI findings including diffusion-weighted imaging lesions (DWILs), and laboratory data, as well as data on rebleeding, global cerebral edema, delayed cerebral ischemia, seizures, the Telephone Interview for Cognitive Status, and the modified Rankin Scale. Eighteen (46%) patients had CMBs. Of these patients, nine had multiple CMBs, and overall a total of 50 CMBs were identified. The most common locations of CMBs were lobar (n=23), followed by deep (n=15) and infratentorial (n=12). After adjustment for age and history of hypertension, CMBs were related to the presence of DWILs (OR, 5.24; 95% CI, 1.14 to 24.00; p = 0.033). Three months after SAH, patients with CMBs had non-significantly higher modified Rankin Scale scores (OR, 2.50; 95% CI, 0.67 to 9.39; p = 0.175). This study suggests that CMBs are commonly observed and associated with DWILs in patients with SAH. Our findings may represent a new mechanism of tissue injury in SAH. Further studies are needed to investigate CMBs' clinical implications.
    Neurosurgery 10/2013; 74(2). DOI:10.1227/NEU.0000000000000244 · 3.03 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The brain is dependent on glucose to meet its energy demands. We sought to evaluate the potential importance of impaired glucose transport by assessing the relationship between brain/serum glucose ratios, cerebral metabolic distress, and mortality after severe brain injury. We studied 46 consecutive comatose patients with subarachnoid or intracerebral hemorrhage, traumatic brain injury, or cardiac arrest who underwent cerebral microdialysis and intracranial pressure monitoring. Continuous insulin infusion was used to maintain target serum glucose levels of 80-120 mg/dL (4.4-6.7 mmol/L). General linear models of logistic function utilizing generalized estimating equations were used to relate predictors of cerebral metabolic distress (defined as a lactate/pyruvate ratio [LPR] ≥ 40) and mortality. A total of 5,187 neuromonitoring hours over 300 days were analyzed. Mean serum glucose was 133 mg/dL (7.4 mmol/L). The median brain/serum glucose ratio, calculated hourly, was substantially lower (0.12) than the expected normal ratio of 0.40 (brain 2.0 and serum 5.0 mmol/L). In addition to low cerebral perfusion pressure (P = 0.05) and baseline Glasgow Coma Scale score (P < 0.0001), brain/serum glucose ratios below the median of 0.12 were independently associated with an increased risk of metabolic distress (adjusted OR = 1.4 [1.2-1.7], P < 0.001). Low brain/serum glucose ratios were also independently associated with in-hospital mortality (adjusted OR = 6.7 [1.2-38.9], P < 0.03) in addition to Glasgow Coma Scale scores (P = 0.029). Reduced brain/serum glucose ratios, consistent with impaired glucose transport across the blood brain barrier, are associated with cerebral metabolic distress and increased mortality after severe brain injury.
    Neurocritical Care 10/2013; 19(3). DOI:10.1007/s12028-013-9919-x · 2.60 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The objective of this study was to investigate the relationship between cardiac index (CI) response to a fluid challenge and changes in brain tissue oxygen pressure (PbtO2) in patients with subarachnoid hemorrhage (SAH). Prospective observational study was conducted in a neurological intensive care unit of a university hospital. Fifty-seven fluid challenges were administered to ten consecutive comatose SAH patients that underwent multimodality monitoring of CI, intracranial pressure (ICP), and PbtO2, according to a standardized fluid management protocol. The relationship between CI and PbtO2 was analyzed with logistic regression utilizing generalized estimating equations. Of the 57 fluid boluses analyzed, 27 (47 %) resulted in a ≥ 10 % increase in CI. Median absolute (+5.8 vs. +1.3 mmHg) and percent (20.7 vs. 3.5 %) changes in PbtO2 were greater in CI responders than in non-responders within 30 min after the end of the fluid bolus infusion. In a multivariable model, a CI response was independently associated with PbtO2 response (adjusted odds ratio 21.5, 95 % CI 1.4-324, P = 0.03) after adjusting for mean arterial pressure change and end-tidal CO2. Stroke volume variation showed a good ability to predict CI and PbtO2 response with areas under the ROC curve of 0.86 and 0.81 with the best cut-off values of 9 % for both responses. Bolus fluid resuscitation resulting in augmentation of CI can improve cerebral oxygenation after SAH.
    Neurocritical Care 09/2013; 20(2). DOI:10.1007/s12028-013-9910-6 · 2.60 Impact Factor
  • 09/2013; 3(3):109-113. DOI:10.1089/ther.2013.1511

Publication Stats

2k Citations
755.65 Total Impact Points

Top Journals

Institutions

  • 2013–2015
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2007–2014
    • Columbia University
      • • Department of Neurology
      • • Department of Neurological Surgery
      New York, New York, United States
  • 2007–2013
    • CUNY Graduate Center
      New York, New York, United States
  • 2012
    • Mount Sinai Hospital
      New York City, New York, United States
  • 2006–2012
    • Barrow Neurological Institute
      Phoenix, Arizona, United States
    • California College San Diego
      San Diego, California, United States
  • 2011
    • New York Presbyterian Hospital
      New York City, New York, United States
  • 2008–2010
    • Intelligent Hearing Systems, Miami, FL USA
      Miami, Florida, United States
    • Mount Sinai School of Medicine
      • Department of Neurosurgery
      Manhattan, NY, United States
  • 2005
    • Harvard Medical School
      • Department of Neurology
      Boston, Massachusetts, United States
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2004
    • Massachusetts General Hospital
      • Department of Neurology
      Boston, MA, United States