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Adamou A, Barkas F, Milionis H, Ntaios G. Glucagon-like peptide-1 receptor agonists and stroke: A systematic review and meta-analysis of cardiovascular outcome trials. Int J Stroke 2024:17474930241253988. [PMID: 38676552 DOI: 10.1177/17474930241253988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
BACKGROUND In patients surviving stroke, approximately 15% and 60% exhibit concurrent diabetes mellitus and overweight/obesity, respectively, necessitating heightened secondary prevention efforts. Despite glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrating improved outcomes for those with diabetes mellitus or obesity, their underutilization persists among eligible individuals. This systematic review and meta-analysis investigated the impact of GLP-1 RAs on stroke risk. The findings aim to optimize the implementation of this therapeutic strategy in patients surviving stroke with diabetes mellitus or obesity. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed MEDLINE and Scopus until 15 November 2023. Eligible studies included randomized cardiovascular outcome trials (CVOTs) with individuals, with or without type 2 diabetes, randomized to either GLP-1 RA or placebo. The outcomes were total strokes, non-fatal strokes, and fatal strokes. Analyses were conducted using RevMan 5.4.1. RESULTS Among 1369 screened studies, 11 were eligible, encompassing 82,140 participants (34.6% women) with a cumulative follow-up of 247,596 person-years. In the GLP-1 RAs group, the stroke rate was significantly lower compared to placebo (RR: 0.85, 95% CI: 0.77-0.93; NNT: 200), showing no heterogeneity or interaction with administration frequency (daily vs weekly). In addition, the GLP-1 RAs group exhibited a significantly lower rate of non-fatal strokes compared to placebo (RR: 0.87, 95% CI: 0.79-0.95; NNT: 250), with no heterogeneity or interaction based on administration frequency, route (oral vs subcutaneous), or diabetes presence. CONCLUSION In this meta-analysis of 11 CVOTs with 82,140 participants, GLP-1 RAs demonstrated a 16% relative reduction in stroke risk compared to placebo. This finding may increase implementation of GLP-1 RAs by stroke specialists in individuals with stroke and comorbid diabetes mellitus or obesity. DATA ACCESS STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Affiliation(s)
- Anastasia Adamou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- First Department of Propaedeutic Internal Medicine, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Fotios Barkas
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Sagris D, Ntaios G, Milionis H. Beyond antithrombotics: recent advances in pharmacological risk factor management for secondary stroke prevention. J Neurol Neurosurg Psychiatry 2024; 95:264-272. [PMID: 37775267 DOI: 10.1136/jnnp-2022-329149] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
Patients with ischaemic stroke represent a diverse group with several cardiovascular risk factors and comorbidities, which classify them as patients at very high risk of stroke recurrence, cardiovascular adverse events or death. In addition to antithrombotic therapy, which is important for secondary stroke prevention in most patients with stroke, cardiovascular risk factor assessment and treatment also contribute significantly to the reduction of mortality and morbidity. Dyslipidaemia, diabetes mellitus and hypertension represent common and important modifiable cardiovascular risk factors among patients with stroke, while early recognition and treatment may have a significant impact on patients' future risk of major cardiovascular events. In recent years, there have been numerous advancements in pharmacological agents aimed at secondary cardiovascular prevention. These innovations, combined with enhanced awareness and interventions targeting adherence and persistence to treatment, as well as lifestyle modifications, have the potential to substantially alleviate the burden of cardiovascular disease, particularly in patients who have experienced ischaemic strokes. This review summarises the evidence on the contemporary advances on pharmacological treatment and future perspectives of secondary stroke prevention beyond antithrombotic treatment.
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Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
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Lip GYH, Lenarczyk R, Pastori D, Ntaios G, Doehner W, Schnabel R. Post-stroke cardiovascular management: Current concepts, integrated care and future developments. Curr Probl Cardiol 2023; 48:101738. [PMID: 37040854 DOI: 10.1016/j.cpcardiol.2023.101738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023]
Abstract
After an ischaemic stroke patients often have cardiovascular complications known as stroke-heart syndrome. The cardiovascular management after stroke has a significant impact on life expectancy as well as the quality of life. The development and implementation of management pathways to improve outcomes for patients with stroke-heart syndrome requires a multidisciplinary involvement from health care professionals from primary, secondary and tertiary prevention levels. A holistic, integrated care approach could follow the ABC pathway: A) Appropriate antithrombotic therapy in all stroke/TIA patients in the acute phase as well as recommendations for the longer term treatment regimen are required to avoid recurrent stroke. B) For better functional and psychological status the assessment of post-stroke cognitive and physical impairment, depression, and anxiety as part of routine post-stroke work-up in every patient is necessary. C) Cardiovascular risk factors and comorbidities management further includes cardiovascular work-up, adapted drug therapy, but often also lifestyle changes that are central to the success of integrated care for stroke-heart syndrome. Greater patient and family/caregiver involvement in planning actions and the input and feedback on optimizing stroke care pathways is needed. Achieving integrated care is challenging and highly context dependent on different healthcare levels. A tailored approach will utilize a variety of enabling factors. In this narrative review, we summarize the current evidence and outline potential factors that will contribute to the successful implementation of integrated cardiovascular care for stroke-heart syndrome management.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Radosław Lenarczyk
- The Medical University of Silesia, Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Daniele Pastori
- Emergency Medicine Unit - Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Renate Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Fatima K, Suri A, Rija A, Kalim S, Javaid S, Arif Z, Abedin MFE, Raza Y, Kalim N, Azam F, Musani S. The Effect of Sodium-Glucose Co-Transporter 2 Inhibitors on Stroke and Atrial Fibrillation: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101582. [PMID: 36584726 DOI: 10.1016/j.cpcardiol.2022.101582] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
The effect of Sodium-glucose cotransporter-2 (SGLT2) inhibitors on the occurrence of AF and stroke remains unclear due to underpowered individual studies. We aim to conduct a meta-analysis including all studies that have evaluated the effects of SGLT2 inhibitors on the occurrence of AF and stroke. We queried electronic databases (PubMed, Cochrane CENTRAL and ClinicalTrials.gov) for randomized controlled trials assessing the effect of SGLT2 inhibitors. Trials were selected if they reported 1 or both of the pre-specified outcomes of stroke and AF. Results were pooled using a random-effects model. Subgroup analysis was conducted to study patients with T2DM, HF, CVD and CKD. 56 trials comprising 111,773 patients were included. SGLT2 inhibitors significantly reduced the incidence of AF across all studies (RR:0.87; 95%CI, [0.76-0.99], P=0.03, I^2=0%) especially when used as monotherapy (RR:0.87; 95%CI, [0.77-0.99], P=0.04, I^2=0%) and among T2DM patients (RR:0.83; 95%CI, [0.72-0.97], P=0.02, I^2=0%). The risk of stroke was not reduced after treatment with SGLT2 inhibitors (RR:0.97; 95%CI, [0.89-1.07], P=0.56, I^2=0%) and this was consistent when given as monotherapy (RR:0.98; 95%CI, [0.89-1.07], P=0.62, I^2=0%) or combination therapy (RR:0.58; 95%CI, [0.17-1.95], P=0.38, I^2=0%). This result was consistent among the 3 subpopulations: T2DM, CVD and HF, however benefit was seen in patients with CKD (eGFR<90) (RR:0.85; 95%CI, [0.75-0.97], P=0.02, I^2=0%). SGLT2 inhibitors significantly reduce the incidence of atrial fibrillation, and this effect is primarily seen when given as monotherapy and in patients with T2DM. However, they have no significant effect on the incidence of stroke, except for in patients with Stage 2 CKD and beyond (eGFR<90).
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Affiliation(s)
- Kaneez Fatima
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Azeema Suri
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Aiman Rija
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
| | - Sara Kalim
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarmad Javaid
- Department of Medicine, Jinnah Sindh Medical University, Karachi, Pakistan
| | - Zainab Arif
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mariam Farhan Essa Abedin
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Yusra Raza
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nimra Kalim
- Department of Medicine, Baqai Medical University, Karachi, Pakistan
| | - Fatima Azam
- Department of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarah Musani
- Department of Internal Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Barkas F, Anastasiou G, Liamis G, Milionis H. A step-by-step guide for the diagnosis and management of hyponatraemia in patients with stroke. Ther Adv Endocrinol Metab 2023; 14:20420188231163806. [PMID: 37033701 PMCID: PMC10074625 DOI: 10.1177/20420188231163806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 02/27/2023] [Indexed: 04/07/2023] Open
Abstract
Hyponatraemia is common in patients with stroke and associated with adverse outcomes and increased mortality risk. The present review presents the underlying causes and provides a thorough algorithm for the diagnosis and management of hyponatraemia in stroke patients. Concomitant diseases and therapies, such as diabetes, chronic kidney disease and heart failure, along with diuretics, antidepressants and proton pump inhibitors are the most common causes of hyponatraemia in community. In the setting of acute stroke, the emergence of hyponatraemia might be attributed to the administration of hypotonic solutions and drugs (ie. mannitol and antiepileptics), poor solute intake, infections, as well as stroke-related conditions or complications, such as the syndrome of inappropriate secretion of antidiuretic hormone, cerebral salt wasting syndrome and secondary adrenal insufficiency. Diagnostically, the initial step is to differentiate hypotonic from non-hypotonic hyponatraemia, usually caused by hyperglycaemia or recent mannitol administration in patients with stroke. Determining urine osmolality, urine sodium level and volume status are the following steps in the differentiation of hypotonic hyponatraemia. Of note, specific parameters, such as fractional uric acid and urea excretion, along with plasma copeptin concentration, may further improve the diagnostic yield. Therapeutic options are based on the duration and symptoms of hyponatremia. In the case of acute or symptomatic hyponatraemia, hypertonic saline administration is recommended. Hypovolaemic chronic hyponatremia is treated with isotonic solution administration. Although fluid restriction remains the first-line treatment for the rest forms of chronic hyponatraemia, therapies increasing renal free water excretion may be necessary. Loop diuretics and urea serve this purpose in patients with stroke, whereas sodium-glucose transport protein-2 inhibitors appear to be a promising therapy. Nevertheless, it is yet unclear whether the appropriate restoration of sodium level improves outcomes in such patients. Randomized trials designed to compare therapeutic strategies in managing hyponatraemia in patients with stroke are required.
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Affiliation(s)
- Fotios Barkas
- Department of Hygiene and Epidemiology, Faculty of
Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Georgia Anastasiou
- Department of Internal Medicine, Faculty of Medicine,
School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, Faculty of Medicine,
School of Health Sciences, University of Ioannina, Ioannina, Greece
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Hsieh CY, Sung SF. From Kidney Protection to Stroke Prevention: The Potential Role of Sodium Glucose Cotransporter-2 Inhibitors. Int J Mol Sci 2022; 24:ijms24010351. [PMID: 36613795 PMCID: PMC9820650 DOI: 10.3390/ijms24010351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Chronic kidney disease (CKD) is an independent risk factor for stroke and covert cerebrovascular disease, and up to 40% of stroke patients have concomitant CKD. However, the so-called "cerebrorenal interaction" attracted less attention compared to its cardiorenal counterpart. Diabetes is the leading cause of CKD. The sodium-glucose cotransporter (SGLT) 2 inhibitor is a relatively new class of oral anti-diabetic drugs and has cardiorenal benefits in addition to glucose-lowering effects. In the present perspective, we would like to review the current status and future potential of the SGLT2 inhibitor in cerebro-renal interactions and strokes regardless of the status of diabetes. We propose the potential roles of baseline renal functions and SGLT1/2 dual inhibition in stroke prevention, as well as the additional benefits of reducing atrial fibrillation and hemorrhagic stroke for SGLT2 inhibitors. Further clinical trials are anticipated to test whether SGLT2 inhibitors can fulfill the long-standing unmet clinical need and stop such a vicious cycle of cerebro-renal interaction.
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Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan 701, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi City 600, Taiwan
- Department of Beauty & Health Care, Min-Hwei Junior College of Health Care Management, Tainan 736, Taiwan
- Correspondence: ; Tel.: +886-5-276-5041 (ext. 7284)
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Tharmaraja T, Ho JS, Sia CH, Lim NA, Chong YF, Lim AY, Rathakrishnan RR, Yeo LL, Sharma VK, Tan BY. Sodium-glucose cotransporter 2 inhibitors and neurological disorders: a scoping review. Ther Adv Chronic Dis 2022; 13:20406223221086996. [PMID: 35432846 PMCID: PMC9006360 DOI: 10.1177/20406223221086996] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/24/2022] [Indexed: 01/24/2023] Open
Abstract
Background Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of antidiabetic medications with a favourable cardiovascular, renal and overall safety profile. Given the limited treatment options available for neurological disorders, it is important to determine whether the pleiotropic effects of SGLT2i can be utilised in their prevention and management. Methods All articles published before 20 March 2021 were systematically searched in MEDLINE, EMBASE, Scopus, Web of Science, APA PsycINFO and ClinicalTrials.gov. Overall, 1395 titles were screened, ultimately resulting in 160 articles being included in the qualitative analysis. Screening and data extraction were conducted by two independent authors and studies were excluded if they were not an original research study. Findings Of the 160 studies, 134 addressed stroke, 19 cognitive impairment, 4 epilepsy and 4 movement disorders, encompassing a range from systematic reviews and randomised controlled trials to bioinformatic and animal studies. Most animal studies demonstrated significant improvements in behavioural and neurological deficits, which were reflected in beneficial changes in neurovascular units, synaptogenesis, neurotransmitter levels and target receptors' docking energies. The evidence from the minority clinical literature was conflicting and many studies did not reach statistical significance. Interpretation SGLT2i may exert neurological benefits through three mechanisms: reduction in cardiovascular risk factors, augmentation of ketogenesis and anti-inflammatory pathways. Most clinical studies were observational, meaning that a causal relationship could not be established, while randomised controlled trials were heterogeneous and powered to detect cardiovascular or renal outcomes. We suggest that a longitudinal study should be conducted and specifically powered to detect neurological outcomes.
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Affiliation(s)
- Thahesh Tharmaraja
- Intensive Care Unit, University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jamie S.Y. Ho
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicole-Ann Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Feng Chong
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Amanda Y.L. Lim
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore
| | - Rahul R. Rathakrishnan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Leonard L.L. Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road Level 11, 119228 Singapore
| | - Vijay K. Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Benjamin Y.Q. Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
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Barkas F, Liberopoulos E, Milionis H. Authors' Reply to: Do All Gliflozins Reduce Stroke in Patients with Type 2 Diabetes Mellitus and Impaired Renal Function? J Stroke Cerebrovasc Dis 2021; 30:105810. [PMID: 33888433 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Fotios Barkas
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Stavrou Niarchou Avenue, Ioannina, Epirus, 45110 Ioannina, Greece
| | - Evangelos Liberopoulos
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Stavrou Niarchou Avenue, Ioannina, Epirus, 45110 Ioannina, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Stavrou Niarchou Avenue, Ioannina, Epirus, 45110 Ioannina, Greece.
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Do all gliflozins reduce stroke in patients with type 2 diabetes mellitus and impaired renal function? J Stroke Cerebrovasc Dis 2021; 30:105799. [DOI: 10.1016/j.jstrokecerebrovasdis.2021.105799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/27/2021] [Indexed: 01/04/2023] Open
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