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Anfray A, Brodin C, Drieu A, Potzeha F, Dalarun B, Agin V, Vivien D, Orset C. Single- and two- chain tissue type plasminogen activator treatments differentially influence cerebral recovery after stroke. Exp Neurol 2021; 338:113606. [PMID: 33453214 DOI: 10.1016/j.expneurol.2021.113606] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
Tissue type Plasminogen Activator (tPA), named alteplase (Actilyse®) under its commercial form, is currently the only pharmacological treatment approved during the acute phase of ischemic stroke, used either alone or combined with thrombectomy. Interestingly, the commercial recombinant tPA (rtPA) contains two physiological forms of rtPA: the single chain rtPA (sc-rtPA) and the two-chains rtPA (tc-rtPA), with differential properties demonstrated in vitro. Using a relevant mouse model of thromboembolic stroke, we have investigated the overall effects of these two forms of rtPA when infused early after stroke onset (i.e. 20 min) on recanalization, lesion volumes, alterations of the integrity of the blood brain barrier and functional recovery. Our data reveal that there is no difference in the capacity of sc-rtPA and tc-rtPA to promote fibrinolysis and reperfusion of the tissue. However, compared to sc-rtPA, tc-rtPA is less efficient to reduce lesion volumes and to improve functional recovery, and is associated with an increased opening of the blood brain barrier. These data indicate better understanding of differential effects of these tPA forms might be important to ultimately improve stroke treatment.
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Affiliation(s)
- Antoine Anfray
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Camille Brodin
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Antoine Drieu
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Fanny Potzeha
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Basile Dalarun
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Véronique Agin
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
| | - Denis Vivien
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France; CHU Caen, Department of Clinical Research, Caen University Hospital, Avenue de la Côte de Nacre, Caen, France.
| | - Cyrille Orset
- Normandie Univ, UNICAEN, INSERM, GIP Cyceron, Institut Blood and Brain @ Caen-Normandie (BB@C), UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Caen, France
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2
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Ma J, Ma Y, Shuaib A, Winship IR. Improved collateral flow and reduced damage after remote ischemic perconditioning during distal middle cerebral artery occlusion in aged rats. Sci Rep 2020; 10:12392. [PMID: 32709950 PMCID: PMC7381676 DOI: 10.1038/s41598-020-69122-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/07/2020] [Indexed: 02/05/2023] Open
Abstract
Circulation through cerebral collaterals can maintain tissue viability until reperfusion is achieved. However, collateral circulation is time limited, and failure of collaterals is accelerated in the aged. Remote ischemic perconditioning (RIPerC), which involves inducing a series of repetitive, transient peripheral cycles of ischemia and reperfusion at a site remote to the brain during cerebral ischemia, may be neuroprotective and can prevent collateral failure in young adult rats. Here, we demonstrate the efficacy of RIPerC to improve blood flow through collaterals in aged (16-18 months of age) Sprague Dawley rats during a distal middle cerebral artery occlusion. Laser speckle contrast imaging and two-photon laser scanning microscopy were used to directly measure flow through collateral connections to ischemic tissue. Consistent with studies in young adult rats, RIPerC enhanced collateral flow by preventing the stroke-induced narrowing of pial arterioles during ischemia. This improved flow was associated with reduced early ischemic damage in RIPerC treated aged rats relative to controls. Thus, RIPerC is an easily administered, non-invasive neuroprotective strategy that can improve penumbral blood flow via collaterals. Enhanced collateral flow supports further investigation as an adjuvant therapy to recanalization therapy and a protective treatment to maintain tissue viability prior to reperfusion.
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Affiliation(s)
- Junqiang Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Yonglie Ma
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada
| | - Ashfaq Shuaib
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R Winship
- Neurochemical Research Unit, Department of Psychiatry, 12-127 Clinical Sciences Building, University of Alberta, Edmonton, AB, T6G 2R3, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
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3
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Abstract
Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.
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Affiliation(s)
- Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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Ng FC, Low E, Andrew E, Smith K, Campbell BC, Hand PJ, Crompton DE, Wijeratne T, Dewey HM, Choi PM. Deconstruction of Interhospital Transfer Workflow in Large Vessel Occlusion. Stroke 2017; 48:1976-1979. [PMID: 28512170 DOI: 10.1161/strokeaha.117.017235] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Interhospital transfer is a critical component in the treatment of acute anterior circulation large vessel occlusive stroke transferred for mechanical thrombectomy. Real-world data for benchmarking and theoretical modeling are limited. We sought to characterize transfer workflow from primary stroke center (PSC) to comprehensive stroke center after the publication of positive thrombectomy trials.
Methods—
Consecutive patients transferred from 3 high-volume PSCs to a single comprehensive stroke center between January 2015 and August 2016 were included in a retrospective study. Factors associated with key time metrics were analyzed with emphasis on PSC intrahospital workflow.
Results—
Sixty-seven patients were identified. Median age was 74 years (interquartile range [IQR], 63.5–78) and National Institutes of Health Stroke Scale 17 (IQR, 12–21). Median transfer time measured by PSC-door-to-comprehensive stroke center-door was 128 minutes (IQR, 107–164), of which 82.8% was spent at PSCs (door-in-door-out [DIDO]; 106 minutes; IQR, 86–143). The lengthiest component of DIDO was computed-tomography-to-retrieval-request (median 59.5 minutes; IQR, 44–83). The 37.3% had DIDO exceeding 120 minutes. DIDO times differed significantly between PSCs (
P
=0.01). In multivariate analyses, rerecruiting the initial ambulance crew for transfer (
P
<0.01) and presentation during working hours (
P
=0.04) were associated with shorter DIDO times.
Conclusions—
In a metropolitan hub-and-spoke network, PSC-door-to-comprehensive stroke center-door and DIDO times are long even in high-volume PSCs. Improving PSC workflow represents a major opportunity to expedite mechanical thrombectomy and improve patient outcomes.
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Affiliation(s)
- Felix C. Ng
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Essie Low
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Emily Andrew
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Karen Smith
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Bruce C.V. Campbell
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Peter J. Hand
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Douglas E. Crompton
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Tissa Wijeratne
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Helen M. Dewey
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
| | - Philip M. Choi
- From the Department of Neurology, Northern Health, Epping, Victoria, Australia (F.C.N., D.E.C.); Department of Neurology, Western Health, St Albans, Victoria, Australia (E.L., T.W.); Research and Evaluation Department, Ambulance Victoria, Melbourne, Australia (E.A., K.S.); Department of Epidemiology and Prevention Medicine, Department of Community Emergency Health and Paramedic Practice (K.S.) and Department of Neurosciences, Eastern Health, Eastern Health Clinical School (H.M.D., P.M.C.), Monash
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Griessenauer CJ, Schirmer CM. Dawn of an Even Newer Era: Mechanical Thrombectomy for Acute Ischemic Stroke Beyond 6 to 8 Hours. World Neurosurg 2017. [PMID: 28645587 DOI: 10.1016/j.wneu.2017.06.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lee TH, Yeh JC, Tsai CH, Yang JT, Lou SL, Seak CJ, Wang CY, Wei KC, Liu HL. Improved thrombolytic effect with focused ultrasound and neuroprotective agent against acute carotid artery thrombosis in rat. Sci Rep 2017; 7:1638. [PMID: 28487554 PMCID: PMC5431649 DOI: 10.1038/s41598-017-01769-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/30/2017] [Indexed: 01/19/2023] Open
Abstract
Combination therapy with focused ultrasound (FUS) and a neuroprotective agent, BNG-1, was examined in an acute carotid thrombotic occlusion model using LED irradiation in rat to improve the thrombolytic effect of rt-PA. Seven treatment groups included (A) intravenous bolus injection of 0.45 mg/kg rt-PA, (B) intravenous bolus injection of 0.9 mg/kg, (C) sonothrombolysis with FUS alone, (D) oral administration of 2 g/kg BNG-1 for 7 days alone, (E) A + D, (F) A + C, and (G) A + C + D. Four comparison groups were made including (H) 0.45 mg/kg rt-PA 20% bolus +80% IV fusion + FUS, (I) 0.9 mg/kg rt-PA with 10% bolus + 90% intravenous fusion, (J) B + C, (K) B + D. At 7 days after carotid occlusion, small-animal carotid ultrasound and 7 T MR angiography showed the recanalization rate of ≤50% stenosis was 50% in group B and 83% in group I, but 0% in groups A and C and 17% in group D. Combination therapy improved recanalization rate to 50–63% in groups E and F, to 67–83% in groups J and K, and to 100% in groups G and H. Our study demonstrated combination therapy with different remedies can be a feasible strategy to improve the thrombolytic effect of rt-PA.
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Affiliation(s)
- Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Jih-Chao Yeh
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Chih-Hung Tsai
- Departments of Electrical Engineering, Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, 333, Taiwan
| | - Jen-Tsung Yang
- Department of Neurosurgery, Chiayi Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Chiayi, Taiwan
| | - Shyh-Liang Lou
- Department of Biomedical Engineering, Chung Yuan Christian University, Chung Li, Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Chao-Yung Wang
- Department of Cardiology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Kuo-Chen Wei
- Department of Neurosurgery, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan.
| | - Hao-Li Liu
- Departments of Electrical Engineering, Graduate Institute of Clinical Medical Sciences, Chang-Gung University, Taoyuan, 333, Taiwan. .,Department of Neurosurgery, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan. .,Institute for Radiological Research, Chang Gung University/Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.
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8
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Khan MA, Baird GL, Miller D, Patel A, Tsekhan S, Yaghi S, Puri A, Jayaraman M, Henninger N, Silver B. Endovascular treatment of acute ischemic stroke in nonagenarians compared with younger patients in a multicenter cohort. J Neurointerv Surg 2016; 9:727-731. [PMID: 27402857 DOI: 10.1136/neurintsurg-2016-012427] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/10/2016] [Accepted: 06/20/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent studies have demonstrated the superiority of endovascular therapy (EVT) for emergent large vessel occlusion. OBJECTIVE To determine the effectiveness of EVT in nonagenarians, for whom data are limited. METHODS We retrospectively reviewed clinical and imaging data of all patients who underwent EVT at two stroke centers between January 2012 and August 2014. The 90-day functional outcome (modified Rankin Scale (mRS) score) was compared between younger patients (age 18-89 years; n=175) and nonagenarians (n=18). The relationship between pre-stroke and 90-day post-stroke mRS was analyzed in these two groups. Multivariable analysis of age, recanalization grade, and admission National Institutes of Health Stroke Scale (NIHSS) for predicting outcome was performed. RESULTS Age ≥90 years was associated with a poor (mRS >2) 90-day outcome relative to those under 90 (89% vs 52%, OR=8, 95% CI 1.7 to 35.0; p=0.0081). Nonagenarians had a higher pre-stroke mRS score (0.77; 95% CI 0.44 to 1.30) than younger patients (0.24; 95% CI 0.17 to 0.35; p=0.005). No difference was observed between nonagenarians and younger patients in the rate of mRS change from pre-stroke to 90 days (p=0.540). On multivariable regression, age (OR=1.05, 95% CI 1.03 to 1.08; p<0.0001), recanalization grade (OR=0.62 95% CI 0.42 to 0.91; p=0.015), and admission NIHSS (OR=1.07 95% CI 1.02 to 1.13; p=0.01) were associated with a poor 90-day outcome. CONCLUSIONS Nonagenarians are at a substantially higher risk of a poor 90-day outcome after EVT than younger patients. However, a small subset of nonagenarians may benefit from EVT, particularly if they have a good pre-stroke functional status. Further research is needed to identify factors associated with favorable outcome in this age cohort.
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Affiliation(s)
- Muhib A Khan
- Department of Neurology, Brown University, Providence, Rhode Island, USA.,Neuroscience Institute (Division of Neurology), Spectrum Health, Michigan State University, Grand Rapids, Michigan, USA
| | - Grayson L Baird
- Lifespan Biostatistics Core, Lifespan Hospital System, Providence, Rhode Island, USA.,Department of Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - David Miller
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Anand Patel
- Department of Neurology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Shawn Tsekhan
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Ajit Puri
- Department of Radiology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, Providence, Rhode Island, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, Massachusetts, USA.,Department of Psychiatry, University of Massachusetts, Worcester, Massachusetts, USA
| | - Brian Silver
- Department of Neurology, Brown University, Providence, Rhode Island, USA
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