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Alshehri A, Panerai RB, Salinet A, Lam MY, Llwyd O, Robinson TG, Minhas JS. A Multi-Parametric Approach for Characterising Cerebral Haemodynamics in Acute Ischaemic and Haemorrhagic Stroke. Healthcare (Basel) 2024; 12:966. [PMID: 38786378 PMCID: PMC11120760 DOI: 10.3390/healthcare12100966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/22/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND PURPOSE Early differentiation between acute ischaemic (AIS) and haemorrhagic stroke (ICH), based on cerebral and peripheral hemodynamic parameters, would be advantageous to allow for pre-hospital interventions. In this preliminary study, we explored the potential of multiple parameters, including dynamic cerebral autoregulation, for phenotyping and differentiating each stroke sub-type. METHODS Eighty patients were included with clinical stroke syndromes confirmed by computed tomography within 48 h of symptom onset. Continuous recordings of bilateral cerebral blood velocity (transcranial Doppler ultrasound), end-tidal CO2 (capnography), electrocardiogram (ECG), and arterial blood pressure (ABP, Finometer) were used to derive 67 cerebral and peripheral parameters. RESULTS A total of 68 patients with AIS (mean age 66.8 ± SD 12.4 years) and 12 patients with ICH (67.8 ± 16.2 years) were included. The median ± SD NIHSS of the cohort was 5 ± 4.6. Statistically significant differences between AIS and ICH were observed for (i) an autoregulation index (ARI) that was higher in the unaffected hemisphere (UH) for ICH compared to AIS (5.9 ± 1.7 vs. 4.9 ± 1.8 p = 0.07); (ii) coherence function for both hemispheres in different frequency bands (AH, p < 0.01; UH p < 0.02); (iii) a baroreceptor sensitivity (BRS) for the low-frequency (LF) bands that was higher for AIS (6.7 ± 4.2 vs. 4.10 ± 2.13 ms/mmHg, p = 0.04) compared to ICH, and that the mean gain of the BRS in the LF range was higher in the AIS than in the ICH (5.8 ± 5.3 vs. 2.7 ± 1.8 ms/mmHg, p = 0.0005); (iv) Systolic and diastolic velocities of the affected hemisphere (AH) that were significantly higher in ICH than in AIS (82.5 ± 28.09 vs. 61.9 ± 18.9 cm/s), systolic velocity (p = 0.002), and diastolic velocity (p = 0.05). CONCLUSION Further multivariate modelling might improve the ability of multiple parameters to discriminate between AIS and ICH and warrants future prospective studies of ultra-early classification (<4 h post symptom onset) of stroke sub-types.
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Affiliation(s)
- Abdulaziz Alshehri
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
- College of Applied Medical Sciences, University of Najran, Najran P.O. Box 1988, Saudi Arabia
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Angela Salinet
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
| | - Man Yee Lam
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
| | - Osian Llwyd
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
- NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Jatinder S. Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (A.A.); (R.B.P.); (A.S.); (M.Y.L.); (T.G.R.)
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Nogueira RC, Aries M, Minhas JS, H Petersen N, Xiong L, Kainerstorfer JM, Castro P. Review of studies on dynamic cerebral autoregulation in the acute phase of stroke and the relationship with clinical outcome. J Cereb Blood Flow Metab 2022; 42:430-453. [PMID: 34515547 PMCID: PMC8985432 DOI: 10.1177/0271678x211045222] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute stroke is associated with high morbidity and mortality. In the last decades, new therapies have been investigated with the aim of improving clinical outcomes in the acute phase post stroke onset. However, despite such advances, a large number of patients do not demonstrate improvement, furthermore, some unfortunately deteriorate. Thus, there is a need for additional treatments targeted to the individual patient. A potential therapeutic target is interventions to optimize cerebral perfusion guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). This narrative led to the development of the INFOMATAS (Identifying New targets FOr Management And Therapy in Acute Stroke) project, designed to foster interventions directed towards understanding and improving hemodynamic aspects of the cerebral circulation in acute cerebrovascular disease states. This comprehensive review aims to summarize relevant studies on assessing dCA in patients suffering acute ischemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage. The review will provide to the reader the most consistent findings, the inconsistent findings which still need to be explored further and discuss the main limitations of these studies. This will allow for the creation of a research agenda for the use of bedside dCA information for prognostication and targeted perfusion interventions.
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Affiliation(s)
- Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Department of Neurology, Hospital Nove de Julho, São Paulo, Brazil
| | - Marcel Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center+, School for Mental Health and Neuroscience (MHeNS), Maastricht, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, USA
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jana M Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, USA.,Neuroscience Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Pedro Castro
- Department of Neurology, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário de São João, Porto, Portugal
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Lee YK, Mazzucco S, Rothwell PM, Payne SJ, Webb AJS. Blood Pressure Complexity Discriminates Pathological Beat-to-Beat Variability as a Marker of Vascular Aging. J Am Heart Assoc 2022; 11:e022865. [PMID: 35043657 PMCID: PMC9238484 DOI: 10.1161/jaha.121.022865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Beat‐to‐beat blood pressure variability (BPV) is associated with an increased risk of stroke but can be driven by both healthy physiological processes and failure of compensatory mechanisms. Blood pressure (BP) complexity measures structured, organized variations in BP, as opposed to random fluctuations, and its reduction may therefore identify pathological beat‐to‐beat BPV. Methods and Results In the prospective, population‐based OXVASC (Oxford Vascular Study) Phenotyped Cohort with transient ischemic attack or minor stroke, patients underwent at least 5 minutes of noninvasive beat‐to‐beat monitoring of BP (Finometer) and ECG to derive the following: BPV (coefficient of variation) and complexity (modified multiscale entropy) of systolic BP and diastolic BP, heart rate variability (SD of R‐R intervals), and baroreflex sensitivity (BRS; Welch's method), in low‐ (0.04–0.15 Hz) and high‐frequency (0.15–0.4 Hz) bands. Associations between BPV or BP complexity with autonomic indexes and arterial stiffness were determined (linear regression), unadjusted, and adjusted for age, sex, and cardiovascular risk factors. In 908 consecutive, consenting patients, BP complexity was inversely correlated with BPV coefficient of variation (P<0.001) and was similarly reduced in patients with hypertension or diabetes (P<0.001). However, although BPV coefficient of variation had a U‐shaped relationship with age, BP complexity fell systematically across age quintiles (quintile 1: 15.1 [14.0–16.1] versus quintile 5: 13.8 [12.4–15.1]) and was correlated with markers of autonomic dysfunction (heart rate variability SD of R‐R intervals: r = 0.20; BRS low frequency: 0.19; BRS high frequency: 0.26) and arterial stiffness (pulse wave velocity: −0.21; all P<0.001), even after adjustment for clinical variables (heart rate variability SD of R‐R intervals: 0.12; BRS low frequency and BRS high frequency: 0.13 and 0.17; and pulse wave velocity: −0.07; all P<0.05). Conclusions Loss of BP complexity discriminates BPV because of pathological failure of compensatory mechanisms and may represent a less confounded and potentially modifiable risk factor for stroke.
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Affiliation(s)
- Yun-Kai Lee
- Institute of Biomedical Engineering Department of Engineering Science University of Oxford UK
| | - Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and DementiaNuffield Department of Clinical NeurosciencesJohn Radcliffe HospitalUniversity of Oxford UK
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and DementiaNuffield Department of Clinical NeurosciencesJohn Radcliffe HospitalUniversity of Oxford UK
| | - Stephen J Payne
- Institute of Biomedical Engineering Department of Engineering Science University of Oxford UK
| | - Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and DementiaNuffield Department of Clinical NeurosciencesJohn Radcliffe HospitalUniversity of Oxford UK
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Olsen MH, Riberholt CG, Mehlsen J, Berg RM, Møller K. Reliability and validity of the mean flow index (Mx) for assessing cerebral autoregulation in humans: A systematic review of the methodology. J Cereb Blood Flow Metab 2022; 42:27-38. [PMID: 34617816 PMCID: PMC8721771 DOI: 10.1177/0271678x211052588] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cerebral autoregulation is a complex mechanism that serves to keep cerebral blood flow relatively constant within a wide range of cerebral perfusion pressures. The mean flow index (Mx) is one of several methods to assess dynamic cerebral autoregulation, but its reliability and validity have never been assessed systematically. The purpose of the present systematic review was to evaluate the methodology, reliability and validity of Mx.Based on 128 studies, we found inconsistency in the pre-processing of the recordings and the methods for calculation of Mx. The reliability in terms of repeatability and reproducibility ranged from poor to excellent, with optimal repeatability when comparing overlapping recordings. The discriminatory ability varied depending on the patient populations; in general, those with acute brain injury exhibited a higher Mx than healthy volunteers. The prognostic ability in terms of functional outcome and mortality ranged from chance result to moderate accuracy.Since the methodology was inconsistent between studies, resulting in varying reliability and validity estimates, the results were difficult to compare. The optimal method for deriving Mx is currently unknown.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gunge Riberholt
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Neurorehabilitation/Traumatic Brain Injury Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ronan Mg Berg
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Centre for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Kirsten Møller
- Department of Neuroanaesthesiology, 53146Rigshospitalet, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Ince J, Mankoo AS, Kadicheeni M, Swienton D, Panerai RB, Robinson TG, Minhas JS. Cerebrovascular tone and resistance measures differ between healthy control and patients with acute intracerebral haemorrhage: exploratory analyses from the BREATHE-ICH study. Physiol Meas 2021; 42. [PMID: 33853052 DOI: 10.1088/1361-6579/abf7da] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/14/2021] [Indexed: 11/12/2022]
Abstract
Objective.Cerebral autoregulation impairment in acute neurovascular disease is well described. The recent BREATHE-ICH study demonstrated improvements in dynamic cerebral autoregulation, by hypocapnia generated by hyperventilation, in the acute period following intracranial haemorrhage (ICH). This exploratory analysis of the BREATHE-ICH dataset aims to examine the differences in hypocapnic responses between healthy controls and patients with ICH, and determine whether haemodynamic indices differ between baseline and hypocapnic states.Approach.Acute ICH patients were recruited within 48 h of onset and healthy volunteers were recruited from a university setting. Transcranial Doppler measurements of the middle cerebral artery were obtained at baseline and then a hyperventilation intervention was used to induce hypocapnia. Patients with ICH were then followed up at 10-14 D post-event for repeated measurements.Main results.Data from 43 healthy controls and 12 patients with acute ICH met the criteria for statistical analysis. In both normocapnic and hypocapnic conditions, significantly higher critical closing pressure and resistance area product were observed in patients with ICH. Furthermore, critical closing pressure changes were observed to be sustained at 10-14 D follow up. During both the normocapnic and hypocapnic states, reduced autoregulation index was observed bilaterally in patients with ICH, compared to healthy controls.Significance.Whilst this exploratory analysis was limited by a small, non-age matched sample, significant differences between ICH patients and healthy controls were observed in factors associated with cerebrovascular tone and resistance. These differences suggest underlying cerebral autoregulation changes in ICH, which may play a pivotal role in the morbidity and mortality associated with ICH.
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Affiliation(s)
- Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Alex S Mankoo
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Meeriam Kadicheeni
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - David Swienton
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
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Lee YK, Rothwell PM, Payne SJ, Webb AJS. Reliability, reproducibility and validity of dynamic cerebral autoregulation in a large cohort with transient ischaemic attack or minor stroke. Physiol Meas 2020; 41:095002. [PMID: 32764198 PMCID: PMC7116588 DOI: 10.1088/1361-6579/abad49] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Cerebral autoregulation (CA) is critical to maintenance of cerebral perfusion but its relevance to the risk of stroke and dementia has been under-studied due to small study sizes and a lack of consensus as to the optimal method of measurement. We determined the reliability and reproducibility of multiple CA indices and the effect of intensive data-processing in a large population with transient ischaemic attack or minor stroke. Approach Consecutive, consenting patients in the population-based OXVASC (Oxford Vascular Study) Phenotyped cohort underwent up to 10-min supine continuous blood pressure monitoring (Finometer) with bilateral middle cerebral artery (MCA) transcranial ultrasound (DWL-Dopplerbox). Un-processed waveforms (Un-A) were median-filtered, systematically reviewed, artefacts corrected and their quality blindly graded (optimal (A) to worst (E)). CA metrics were derived in time-domain (autoregulatory index (ARI), Pearson’s Mx, Sx, Dx) and in very-low (VLF) and low-frequency (LF) domains (WPS-SI: wavelet phase synchronisation, transfer function analysis), stratified by recording quality. Reliability and reproducibility (Cronbach’s Alpha) were determined comparing MCA sides and the first vs. second 5-min of monitoring. Main results In 453 patients, following manual data-cleaning, there was good reliability of indices when comparing MCA sides (Mx: 0.77; WPS-SI-VLF: 0.85; WPS-SI-LF 0.84), or repeated five minute epochs (Mx: 0.57; WPS-SI-VLF: 0.69; WPS-SI-LF 0.90), with persistently good reliability between sides even in lower quality Groups (Group D: Mx: 0.79; WPS-SI-VLF: 0.92; WPS-SI-LF: 0.91). Reliability was greatest for Pearson’s Mx and wavelet synchronisation index, with reasonable reliability of transfer function analyses, but ARI was prone to occasional, potentially defective, extreme estimates (Left vs right MCA: 0.68). Significance Resting-state measures of CA were valid, reproducible and robust to moderate noise, but require careful data-processing. Mx and wavelet synchronisation index were the most reliable indices for determining the prognostic value of CA in large epidemiological cohorts and its potential as a treatment target.
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Affiliation(s)
- Yun-Kai Lee
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, United Kingdom
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Minhas JS, Panerai RB, Ghaly G, Divall P, Robinson TG. Cerebral autoregulation in hemorrhagic stroke: A systematic review and meta-analysis of transcranial Doppler ultrasonography studies. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:14-21. [PMID: 30270441 DOI: 10.1002/jcu.22645] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/09/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE International guidelines advocate intensive blood pressure (BP) lowering within 6 hours of acute intracerebral hemorrhage (ICH) to a target systolic BP of 130-140 mm Hg, though more intensive lowering may be associated with adverse outcome. Observational studies suggest impaired cerebral autoregulation (CA) following ICH. Transcranial Doppler ultrasonography (TCD), alongside continuous BP monitoring, provides a noninvasive bedside investigation that offers detailed perspectives on physiological perturbations post-acute ICH. This systematic review and meta-analysis focuses on all TCD studies of CA in ICH. METHODS MEDLINE, EMBASE, and CENTRAL were searched for studies of hemorrhagic stroke and blood flow measurement. RESULTS Eight studies met inclusion criteria (293 ICH patients); CA was impaired up to 12-days post-acute ICH. Impaired CA was evidenced by reduced transfer function analysis phase and higher mean flow correlation values: these were associated with worsened clinical parameters including ICH-volume and Glasgow Coma Scale. Meta-analysis of CBV demonstrated that, compared to controls, mean CBV was significantly lower in the ipsilateral (49.7 vs 64.8 cm s-1 , Z = 4.26, P < .0001) and contralateral hemispheres following ICH (51.5 vs 64.8 cm s-1 , Z = 3.44, P = .0006). CONCLUSION Lower mean CBV in combination with impaired CA may have implications for more intensive BP lowering and warrants further studies examining such strategies on cerebral blood flow and its regulatory mechanisms.
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Affiliation(s)
- Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Ronney B Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - George Ghaly
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Pip Divall
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Thompson G Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
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