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Diener HC, Weimar C, Weber R. Antiplatelet therapy in secondary stroke prevention--state of the art. J Cell Mol Med 2011; 14:2552-60. [PMID: 20738444 PMCID: PMC4373475 DOI: 10.1111/j.1582-4934.2010.01163.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Our objective is to provide the reader with an overview as well as an update on current antiplatelet therapy for secondary stroke prevention. Relevant journals were hand-searched by the authors to compile a broad but by far not comprehensive summary of innovative and clinically relevant studies. Aspirin, clopidogrel and the combination of dipyridamole plus aspirin are the cornerstone therapy in secondary prevention after non-cardio-embolic stroke or transient ischaemic attack. A head-to-head comparison showed no difference in the prevention of recurrent stroke between dipyridamole plus aspirin and clopidogrel. More potent antiplatelet drugs or the combination of aspirin and clopidogrel prevent more ischaemic events, but also lead to more bleeding complications. For secondary stroke prevention in patients with atrial fibrillation, oral anticoagulation is more effective than aspirin or the combination of aspirin and clopidogrel.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neurology and Stroke Center, University Duisburg-Essen, Essen, Germany.
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von Weitzel-Mudersbach P, Johnsen SP, Andersen G. Low risk of vascular events following urgent treatment of transient ischaemic attack: the Aarhus TIA study. Eur J Neurol 2011; 18:1285-90. [PMID: 21645177 DOI: 10.1111/j.1468-1331.2011.03452.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Patients with TIA have a high short-time risk of stroke and an increased long-term risk of ischaemic vascular events compared with the general population. Urgent intervention may reduce short-time stroke risk, but little is known about the effect beyond 3 months. We examined 1-year outcome and risk factor management in patients with TIA after urgent intervention. METHODS All patients with TIA referred to Aarhus University Hospital 1 March 2007-28 February 2008 were seen by an acute TIA team (ATT), integrating outpatient care and stroke unit facilities. Preventive treatment was initiated immediately, including fast-track surgery for carotid stenosis. Follow-up including nurse-conducted health counseling was carried out after 7, 90, and 365 days. RESULTS A total of 306 patients were included. Stroke, myocardial infarction, or vascular death occurred in 5.2% during 1 year of follow-up. The cumulated stroke rate was 1.6%, 2.0%, and 4.4% after 7, 90, and 365 days, respectively, compared to expected 4.5% [relative risk (RR) 0.36, 95% CI 0.13-0.98] and 7.5% (RR 0.26, 95% CI 0.11-0.63) after 7 and 90 days using ABCD(2) criteria. Recurrent TIA occurred in 10.2% (n = 32). Secondary prevention targets were attained in 47.6% after 1 year. Carotid surgery was performed in 8.1%; median time to operation was 11 days after contact with the ATT. CONCLUSION Urgent intervention after TIA by an ATT covering outpatient and stroke unit facilities combined with nurse-conducted health counseling is associated with a low 1-year risk of new vascular events and may improve risk factor control.
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Huttner HB, Köhrmann M, Mauer C, Lücking H, Kloska S, Doerfler A, Schwab S, Schellinger PD. The Prevalence of Peripheral Arteriopathy is Higher in Ischaemic Stroke as Compared with Transient Ischaemic Attack and Intracerebral Haemorrhage. Int J Stroke 2010; 5:278-83. [DOI: 10.1111/j.1747-4949.2010.00440.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: There is little data on the association of peripheral arterial disease and stroke. We aimed to assess the prevalence of peripheral arterial disease in acute stroke and to identify the predisposing factors for peripheral arterial disease in a stroke cohort. Methods: We enrolled all consecutive patients who were admitted to our stroke- and neurocritical care units with the diagnosis of a transient ischaemic attack, ischaemic or haemorrhagic stroke over a period of 5 months. As controls, we analysed 50 nonvascular neurological patients who were matched to age. Upon admission, assessment of the ankle brachial index was performed in all patients. The only exclusion criteria was decompensated congestive heart failure. Results: Altogether, we compared 374 stroke patients (95 transient ischaemic attack, 231 ischaemic, and 48 haemorrhagic strokes) and 50 nonstroke controls. The prevalence of peripheral arterial disease in the control group was 14%. There was a trend towards a higher prevalence of peripheral arterial disease in stroke patients (χ2-test: P = 0.051; prevalence peripheral arterial disease in transient ischaemic attack: 16.8%, ischaemic stroke: 32%, and haemorrhagic stroke: 20.8%). A higher proportion of ischaemic stroke patients were peripheral arterial disease-positive, compared with transient ischaemic attack patients ( P = 0.005) and controls ( P = 0.011), respectively. Multivariate regression analyses identified the parameters age, arterial hypertension, current or former smokers and a history of cardiovascular events to be predisposing factors of peripheral arterial disease. Conclusion: This study represents the first systematic investigation of the prevalence of peripheral arterial disease in stroke. By now, it is clear that: • peripheral arterial disease is more commonly found in stroke than in nonstroke patients • ischaemic stroke patients show the highest prevalence of peripheral arterial disease, and • peripheral arterial disease in stroke is related to common vascular risk factors.
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Affiliation(s)
| | | | - Christoph Mauer
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Hannes Lücking
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Stephan Kloska
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen, Erlangen, Germany
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Manzano L, Mostaza JM, Suarez C, Del Valle FJ, Ortiz JA, Sampedro JL, Pose A, Roman P, Vieitez P, Sánchez-Zamorano MA. Prognostic value of the ankle-brachial index in elderly patients with a stable chronic cardiovascular event. J Thromb Haemost 2010; 8:1176-84. [PMID: 20230414 DOI: 10.1111/j.1538-7836.2010.03841.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with polyvascular arterial disease have a greater risk of suffering a new atherothrombotic episode than those with involvement of only one vascular territory. We have studied the predictive prognostic value of the detection of non-diagnosed peripheral arterial disease, determined by measuring the ankle-brachial index in a population of elderly patients with stable chronic cardiac or cerebrovascular disease. METHODS This was a multicenter, prospective cohort study with consecutive inclusion of patients between 65 and 85 years of age with a previous atherothrombotic event, but without previously established peripheral arterial disease. RESULTS A total of 1096 patients were evaluated during 11.7 (+ or - 2.2) months of follow-up. An ankle-brachial index of < 0.9 was observed in 29.9% and > 1.4 in 6.9%. The detection of an ankle-brachial index < 0.9 was clearly associated with the presence of a combined primary event of cardiovascular death and non-fatal cardiovascular event [HR 1.99 (95% CI, 1.49-2.66; P < 0.001)]. There was also a significant relationship between ankle-brachial index > 1.4 and total (P = 0.001) or cardiovascular (P = 0.020) deaths. The predictive value of both ranges of the ankle-brachial index was maintained after adjusting for age, sex, diabetes mellitus, vascular territory, macroalbuminuria or glomerular filtration rate. CONCLUSIONS The detection of non-diagnosed peripheral arterial disease in patients with stable coronary or cerebrovascular events identifies a very high risk population that might benefit from more intensive treatment.
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Affiliation(s)
- L Manzano
- Heart Failure and Vascular Risk Unit, Internal Medicine Department, Hospital Ramón y Cajal, Universidad de Alcalá, Madrid, Spain.
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Weimar C, Benemann J, Michalski D, Müller M, Luckner K, Katsarava Z, Weber R, Diener HC. Prediction of Recurrent Stroke and Vascular Death in Patients With Transient Ischemic Attack or Nondisabling Stroke. Stroke 2010; 41:487-93. [PMID: 20056932 DOI: 10.1161/strokeaha.109.562157] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Several predictive scores have been developed and validated for stratifying cerebrovascular patients based on the risk of future (cerebro)vascular events. We aimed to prospectively compare the predictive accuracy of the Essen Stroke Risk Score, Stroke Prognostic Instrument, Hankey score, and the Life Long After Cerebral ischemia score.
Methods—
Between August 2005 and December 2006, we included 2381 patients from 10 German stroke centers with an acute nondisabling ischemic stroke or transient ischemic attack and with prospective assessment of clinical variables for calculation of the predictive scores. A total of 1897 patients (79.7%) could be followed up for a median of 1 year. To evaluate the performance of each model, we calculated the area under the curve by receiver operating characteristic. In addition, we used the recommended cutoff values for calculation of sensitivity and specificity for stroke or the combined outcome of stroke or cardiovascular death.
Results—
The Kaplan–Meier estimate for the overall annual stroke risk was 4.8% and for recurrent stroke or cardiovascular death 6.6%. We could confirm the predictive value of all 4 previously developed scores with a marginally superior performance of the SPI-II.
Conclusions—
In patients with acute nondisabling ischemic stroke or transient ischemic attack, all 4 scores are able to stratify the risk of recurrent stroke or the combined outcome. Simple point scores (Essen Stroke Risk Score, Stroke Prognostic Instrument) may help to raise awareness for medical prevention in clinical routine and increase compliance with risk factor modification.
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Affiliation(s)
- Christian Weimar
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Jens Benemann
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Dominik Michalski
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Martin Müller
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Konrad Luckner
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Zaza Katsarava
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Ralph Weber
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
| | - Hans-Christoph Diener
- From the Department of Neurology (C.W., J.B., Z.K., R.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Department of Neurology (D.M.), University of Leipzig, Leipzig, Germany; the Department of Neurology (M.M.), Klinikum Bernburg, Bernburg, Germany; and the Department of Neurology (K.L.), Krankenhaus Buchholz Steinbecker, Buchholz, Germany
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Busch MA, Lutz K, Röhl JE, Neuner B, Masuhr F. Low Ankle-Brachial Index Predicts Cardiovascular Risk After Acute Ischemic Stroke or Transient Ischemic Attack. Stroke 2009; 40:3700-5. [DOI: 10.1161/strokeaha.109.559740] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A low ankle-brachial blood pressure index (ABI) is an established risk marker for cardiovascular disease and mortality in the general population, but little is known about its prognostic value in individuals with acute ischemic stroke or transient ischemic attack (TIA).
Methods—
An inception cohort of 204 patients with acute ischemic stroke or TIA was followed up for a mean of 2.3 years. At baseline, patients underwent ABI measurement and were assessed for risk factors, cardiovascular comorbidities, and cervical or intracranial artery stenosis. The association between low ABI (≤0.9) and the risk of the composite outcome of stroke, myocardial infarction, or death was examined by Kaplan-Meier and Cox regression analyses.
Results—
A low ABI was found in 63 patients (31%) and was associated with older age, current smoking, hypertension, peripheral arterial disease, and cervical or intracranial stenosis. During a total of 453.0 person-years of follow-up, 37 patients experienced outcome events (8.2% per person-year), with a higher outcome rate per person-year in patients with low ABI (12.8% vs 6.3%,
P
=0.03). In survival analysis adjusted for age and stroke etiology, patients with a low ABI had a 2 times higher risk of stroke, myocardial infarction, or death than those with a normal ABI (hazard ratio=2.2; 95% CI, 1.1 to 4.5). Additional adjustment for risk factors and cardiovascular comorbidities did not attenuate the association.
Conclusions—
A low ABI independently predicted subsequent cardiovascular risk and mortality in patients with acute stroke or TIA. ABI measurement may help to identify high-risk patients for targeted secondary stroke prevention.
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Affiliation(s)
- Markus A. Busch
- From the Department of Epidemiology (M.A.B.), Robert Koch Institute, Berlin, Germany; Department of Neurology (M.A.B., K.L., J.-E.R., F.M.), Charité-Universitätsmedizin Berlin, Berlin, Germany; and Institute of Epidemiology and Social Medicine (B.N.), Clinical Epidemiology Section, University of Muenster, Muenster, Germany
| | - Katrin Lutz
- From the Department of Epidemiology (M.A.B.), Robert Koch Institute, Berlin, Germany; Department of Neurology (M.A.B., K.L., J.-E.R., F.M.), Charité-Universitätsmedizin Berlin, Berlin, Germany; and Institute of Epidemiology and Social Medicine (B.N.), Clinical Epidemiology Section, University of Muenster, Muenster, Germany
| | - Jens-Eric Röhl
- From the Department of Epidemiology (M.A.B.), Robert Koch Institute, Berlin, Germany; Department of Neurology (M.A.B., K.L., J.-E.R., F.M.), Charité-Universitätsmedizin Berlin, Berlin, Germany; and Institute of Epidemiology and Social Medicine (B.N.), Clinical Epidemiology Section, University of Muenster, Muenster, Germany
| | - Bruno Neuner
- From the Department of Epidemiology (M.A.B.), Robert Koch Institute, Berlin, Germany; Department of Neurology (M.A.B., K.L., J.-E.R., F.M.), Charité-Universitätsmedizin Berlin, Berlin, Germany; and Institute of Epidemiology and Social Medicine (B.N.), Clinical Epidemiology Section, University of Muenster, Muenster, Germany
| | - Florian Masuhr
- From the Department of Epidemiology (M.A.B.), Robert Koch Institute, Berlin, Germany; Department of Neurology (M.A.B., K.L., J.-E.R., F.M.), Charité-Universitätsmedizin Berlin, Berlin, Germany; and Institute of Epidemiology and Social Medicine (B.N.), Clinical Epidemiology Section, University of Muenster, Muenster, Germany
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Purroy F, Coll B, Oró M, Setó E, Piñol-Ripoll G, Plana A, Quílez A, Sanahuja J, Brieva L, Vega L, Fernández E. Predictive value of ankle brachial index in patients with acute ischaemic stroke. Eur J Neurol 2009; 17:602-6. [DOI: 10.1111/j.1468-1331.2009.02874.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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58
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Association of Asymptomatic Peripheral Arterial Disease With Vascular Events in Patients With Stroke or Transient Ischemic Attack. Stroke 2009; 40:3472-7. [DOI: 10.1161/strokeaha.109.559278] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Diener HC, Weimar C. Update of secondary stroke prevention. Nephrol Dial Transplant 2009; 24:1718-24. [PMID: 19244225 PMCID: PMC2721463 DOI: 10.1093/ndt/gfp068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 02/03/2009] [Indexed: 12/31/2022] Open
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Weimar C, Diener HC, Alberts MJ, Steg PG, Bhatt DL, Wilson PW, Mas JL, Röther J. The Essen Stroke Risk Score Predicts Recurrent Cardiovascular Events. Stroke 2009; 40:350-4. [PMID: 19023098 DOI: 10.1161/strokeaha.108.521419] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christian Weimar
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Hans-Christoph Diener
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Mark J. Alberts
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - P. Gabriel Steg
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Deepak L. Bhatt
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Peter W.F. Wilson
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Jean-Louis Mas
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
| | - Joachim Röther
- From the Department of Neurology (C.W., H.-C.D.), University of Duisburg-Essen, Essen, Germany; the Division of Neurology (M.J.A.), Northwestern University Medical School, Chicago, Ill; INSERM U-698 and APHP (Hôpital Bichat-Claude Bernard; P.G.S.), Université Paris 7, France; the Department of Cardiovascular Medicine (D.L.B.), Cleveland Clinic, Cleveland, Ohio; the Cardiology Division (P.W.F.W.), Emory University School of Medicine, Atlanta, Ga; Service de Neurologie (J.-L.M.), Centre Raymond
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