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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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Rangel I, Palmisciano P, Vanderhye VK, El Ahmadieh TY, Wahood W, Demaerschalk BM, Sands KA, O’Carroll CB, Krishna C, Zimmerman RS, Chong BW, Bendok BR, Turkmani AH. Optimizing Door-to-Groin Puncture Time: The Mayo Clinic Experience. Mayo Clin Proc Innov Qual Outcomes 2022; 6:327-336. [PMID: 35801155 PMCID: PMC9253412 DOI: 10.1016/j.mayocpiqo.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES To provide a better understanding of methods that can be used to improve patient outcomes by reducing the door-to-groin puncture (DTP) time and present the results of a stroke quality improvement project (QIP) conducted by Mayo Clinic Arizona's stroke center. METHODS We conducted a systematic literature search of Ovid MEDLINE(R), Ovid EMBASE, Scopus, and Web of Science for studies that evaluated DTP time reduction strategies. Those determined eligible for the purpose of this analysis were assessed for quality. The strategies for DTP time reduction were categorized on the basis of modified Target: Stroke Phase III recommendations and analyzed using a meta-analysis. The Mayo Clinic QIP implemented a single-call activation system to reduce DTP times by decreasing the time from neurosurgery notification to case start. RESULTS Fourteen studies were selected for the analysis, consisting of 2277 patients with acute ischemic stroke secondary to large-vessel occlusions. After intervention, all the studies showed a reduction in the DTP time, with the pooled DTP improvement being the standardized mean difference (1.37; 95% confidence interval, 1.20-1.93; τ2=1.09; P<.001). The Mayo Clinic QIP similarly displayed a DTP time reduction, with the DTP time dropping from 125.1 to 82.5 minutes after strategy implementation. CONCLUSION Computed tomography flow modifications produced the largest and most consistent reduction in the DTP time. However, the reduction in the DTP time across all the studies suggests that any systematic protocol aimed at reducing the DTP time can produce a beneficial effect. The relative novelty of mechanical thrombectomy and the consequential lack of research call for future investigation into the efficacy of varying DTP time reduction strategies.
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Affiliation(s)
- India Rangel
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Vanesa K. Vanderhye
- Department of Neurology, Mayo Clinic, Phoenix, AZ
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
| | - Tarek Y. El Ahmadieh
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL
| | | | | | | | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
| | | | - Brian W. Chong
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
- Department of Radiology, Mayo Clinic, Phoenix, AZ
| | | | - Ali H. Turkmani
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ
- Correspondence: Address to Ali H. Turkmani, MD, Department of Neurological Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054 9.
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Kim SC, Lee CY, Kim CH, Sohn SI, Hong JH, Park H. The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration. J Cerebrovasc Endovasc Neurosurg 2021; 24:24-35. [PMID: 34696551 PMCID: PMC8984638 DOI: 10.7461/jcen.2021.e2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization. Methods A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration. Results Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p>0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p<0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p>0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p<0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p<0.05), and 79.1±47.5 vs. 58.4±75.3 (p<0.05) in three steps, respectively. Conclusions We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.
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Affiliation(s)
- Su Chel Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
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Janssen PM, Venema E, Dippel DW. Effect of Workflow Improvements in Endovascular Stroke Treatment. Stroke 2019; 50:665-674. [DOI: 10.1161/strokeaha.118.021633] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Paula M. Janssen
- From the Department of Neurology (P.M.J., E.V., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Esmee Venema
- From the Department of Neurology (P.M.J., E.V., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (E.V.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W.J. Dippel
- From the Department of Neurology (P.M.J., E.V., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. Korean J Radiol 2018; 19:838-848. [PMID: 30174472 PMCID: PMC6082772 DOI: 10.3348/kjr.2018.19.5.838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/01/2023] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention (NI) team for EVT candidate prior to imaging, NI team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan 49201, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul 02841, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 13620, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon 16499, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang 10380, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul 06973, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul 06351, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan 50612, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul 03722, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon 22332, Korea
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Kim DH, Kim B, Jung C, Nam HS, Lee JS, Kim JW, Lee WJ, Seo WK, Heo JH, Baik SK, Kim BM, Rha JH. Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time. J Korean Med Sci 2018; 33:e143. [PMID: 29736159 PMCID: PMC5934519 DOI: 10.3346/jkms.2018.33.e143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/20/2018] [Indexed: 11/20/2022] Open
Abstract
Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention team for EVT candidate prior to imaging, neurointervention team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.
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Affiliation(s)
- Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jin Woo Kim
- Department of Radiology, Inje Univeristy Ilsan Paik Hospital, Goyang, Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Woo-Keun Seo
- Department of Neurology, Sungkyunkwan University, Samsung Medical Center, Seoul, Korea
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University Severance Hospital, Seoul, Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University Severance Hospital, Seoul, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University Hospital, Incheon, Korea
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Streamlining Workflow for Endovascular Mechanical Thrombectomy: Lessons Learned from a Comprehensive Stroke Center. J Stroke Cerebrovasc Dis 2017; 26:1655-1662. [PMID: 28579511 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 04/18/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays. METHODS The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed. RESULTS The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays. CONCLUSIONS We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients.
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Aghaebrahim A, Streib C, Rangaraju S, Kenmuir CL, Giurgiutiu DV, Horev A, Saeed Y, Callaway CW, Guyette FX, Martin-Gill C, Pacella C, Ducruet AF, Jankowitz BT, Jovin TG, Jadhav AP. Streamlining door to recanalization processes in endovascular stroke therapy. J Neurointerv Surg 2016; 9:340-345. [DOI: 10.1136/neurintsurg-2016-012324] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/08/2016] [Accepted: 03/12/2016] [Indexed: 11/04/2022]
Abstract
BackgroundIn acute stroke due to large vessel occlusion, faster reperfusion leads to better outcomes. We analyzed the effect of optimization steps aimed to reduce treatment delays at our center.MethodsConsecutive patients with ischemic stroke treated with endovascular therapy were prospectively analyzed. We divided the patients into pre-optimization (20 April 2012 to 8 October 2013) and post-optimization (9 October 2013 to 29 July 2014) periods. The main interventions included: (1) continuous feedback; (2) standardized immediate emergency department attending to stroke attending communication with interventional team activation for all potential interventions; (3) pre-notification by the emergency medical service; (4) minimizing additional diagnostic testing; (5) direct transport to the CT scanner; (6) transport directly from the CT scanner to the angiography suite. The main metric used to measure improvement was door to groin puncture time (D2P).ResultsWe included a total of 286 patients (178 pre-optimization, 108 post-optimization). There were no significant differences between major baseline characteristics between the groups with the exception of higher median CT Alberta Stroke Program Early CT Score in the pre-optimization group (p=0.01). Median D2P improved from 105 min pre-optimization to 67 min post-optimization (p=0.0002). Rates of good clinical outcomes (modified Rankin Scale 0–2 at 3 months) were similar in both groups, with a trend toward a better outcome in the post-optimization group in a subgroup analysis of patients with anterior circulation occlusion who received intravenous tissue plasminogen activator.ConclusionsThis pilot study demonstrates that D2P times can be significantly reduced with a standardized multidisciplinary approach. There was no significant difference in the rate of 3-month good outcome, which is most likely due to the small sample size and confounding baseline patient characteristics.
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Preprocedure change in arterial occlusion in acute ischemic stroke patients undergoing endovascular treatment by computed tomographic angiography. Am J Emerg Med 2015; 33:631-4. [DOI: 10.1016/j.ajem.2015.01.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/28/2015] [Accepted: 01/29/2015] [Indexed: 11/16/2022] Open
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Abstract
More than 30 years after initial reports demonstrated the feasibility of intra-arterial or endovascular therapies for the treatment of acute ischemic stroke, big data have finally established requisite evidence for the safety and efficacy of thrombectomy. Cautious enthusiasm for this breakthrough is tempered, as we await the bigger data of these trials to understand the constellation of variables that ensured success. Noninvasive imaging, including multimodal computed tomography and MRI as used in recent endovascular trials, has dramatically advanced since that time, providing snapshots or profiles of the collaterome in a given patient. Data-driven analyses will provide the most potent argument to distinguish comprehensive stroke centers from interventional-ready sites. These trials may provide insight on the future role of telestroke, for intravenous thrombolysis and remote imaging review of multimodal computed tomography or MRI to streamline patient transfer for endovascular therapy. Rather than concluding that recent trials have answered the most important question regarding endovascular therapy, even more data are needed to effectively translate such success and extend such potential benefit to the greatest number of stroke patients encountered on a daily basis.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core, UCLA Department of Neurology, Neuroscience Research Building, 635 Charles E Young Drive South, Suite 225, Los Angeles, CA 90095-7334, USA
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