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Karedath J, Avanteeka FNU, Nouman Aslam M, Nadeem A, Yousaf RA, Shah S, Palleti SK, Khan A. Comparison of Effectiveness and Safety of Low-Dose Versus Standard-Dose Intravenous Recombinant Tissue Plasminogen Activator in Patients With Acute Ischemic Stroke: A Meta-Analysis. Cureus 2023; 15:e35571. [PMID: 37007347 PMCID: PMC10062115 DOI: 10.7759/cureus.35571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 03/04/2023] Open
Abstract
The aim of the present meta-analysis is to compare the efficacy and safety of low-dose and standard-dose recombinant tissue plasminogen activators (r-tPA) in patients with acute ischemic stroke. The present meta-analysis was conducted according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted a systematic search in PubMed, Embase, and the Cochrane Library to identify studies published between January 1, 2010, and January 31, 2023, using the following terms: "stroke," "alteplase," "doses," "efficacy," "tissue plasminogen activator," "r-tPA," and "safety." Primary efficacy outcomes included favorable outcomes (Modified Rankin Scale scores of 0-2), while secondary efficacy outcome was all-cause mortality at 90 days. Safety outcomes included asymptomatic intracerebral hemorrhage (ICH) and symptomatic ICH assessed using the National Institute of Neurological Disorders and Stroke (NINDS) study and the Safe Implementation of Thrombolysis in Stroke-Monitoring (SITS-MOST) study. We also compared parenchymal hematomas as safety outcome between the two groups defined by the authors themselves in their research. A total of 16 studies were included in the present meta-analysis. The meta-analysis did not report any significant difference between low-dose and standard-dose r-tPA in terms of mortality, symptomatic intracranial hemorrhage (SICH), asymptomatic ICH, and parenchymal hematomas. However, the favorable outcome was significantly greater in patients receiving a standard dose of r-tPA.
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Eldeeb HM, Elsalamawy DH, Elabd AM, Abdelraheem HS. Predictors of the functional outcome after thrombolysis in an Egyptian patients’ sample. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-020-00261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
About 6.2 million individuals worldwide and approximately 200 Egyptians/100,000 citizens have cerebrovascular stroke annually, and only less than 1% of stroke patients received intravenous (IV) thrombolysis in 2014. Outcome of the ischemic stroke after IV thrombolysis varies, and there is lack of data about the predicting factors that contributes to the outcome of ischemic strokes after IV thrombolysis in Egypt.
Objective
The aim of this work is to study the predictors of the functional outcome of ischemic cerebrovascular stroke after IV thrombolysis in Egyptian patients.
Patients and methods
This is a prospective study that includes acute ischemic stroke patients who received IV thrombolysis at the Alexandria University Hospital during the year from February 2017 to February 2018, and they were evaluated initially by Rapid Arterial Occlusion Evaluation (RACE) scale and followed-up serially for 6 months after thrombolysis using the National Institutes of Health Stroke Scale (NIHSS) and modified ranking score (mRS).
Results
Forty-five patients are included; 56% had favorable functional outcome (mRS 0–2) after 6 months, 68% had ≥ 4 points improvement in NIHSS after 6 months, and 13% had hemorrhagic conversion with 18% mortality rate. High initial RACE scale and long hospital stay are associated with poor functional outcome 6 months after thrombolysis.
Conclusion
Stroke severity demonstrated by high initial RACE and the duration of hospital stay are the two most significant predictors with an impact on the functional outcome of ischemic cerebrovascular stroke after thrombolysis.
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Couture M, Marnat G, Griffier R, Gariel F, Olindo S, Renou P, Sagnier S, Berge J, Tourdias T, Sibon I. Antiplatelet therapy increases symptomatic ICH risk after thrombolysis and thrombectomy. Acta Neurol Scand 2021; 144:500-508. [PMID: 34042170 DOI: 10.1111/ane.13468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/29/2021] [Accepted: 04/21/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The influence of chronic treatment by antiplatelet drug (APD) at stroke onset on the outcomes of patients with acute ischemic stroke (AIS) treated with combined intravenous thrombolysis (IVT) and endovascular therapy (EVT) is unclear. We investigated whether prior APD use influences the risk of symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients treated with combined reperfusion therapy. METHODS A single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent IVT and EVT between January 2015 and May 2017. The main outcomes were the incidence of sICH using the Heidelberg Bleeding Classification and patients' functional status at 90 days, as defined by the modified Rankin scale (mRS). Outcomes were evaluated according to daily exposure to APD, and associations were assessed using multivariate logistic regression analysis. RESULTS This study included 204 patients: 71 (34.8%) were taking APD before AIS. Patients with chronic treatment by APD at stroke onset had a higher rate of sICH (26.7% vs. 3.7%; p< .001) and worse functional outcome (mRS >2) at 90 days (69% vs. 36.8%; p < .001). Prior APD use was associated with an increased likelihood of sICH (OR 9.8; 95%CI [3.6-31.3], p < .05) and of functional dependence at 90 days (OR 5.72; 95%CI [2.09-1.72], p < .001), independent of confounders on multivariate analysis. CONCLUSIONS Chronic treatment by APD at stroke onset in AIS patients with proximal intracranial occlusion treated using IVT and EVT increases the risk of sICH and worsens the functional prognosis. Further investigation to refine acute revascularization strategies in this population might be required.
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Affiliation(s)
- Marie Couture
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
| | - Gaultier Marnat
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | - Romain Griffier
- CHU de Bordeaux Pôle de Santé Publique Service d’information médicale Bordeaux France
| | - Florent Gariel
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | | | - Pauline Renou
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
| | - Sharmila Sagnier
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
- UMR 5287 CNRS Université de Bordeaux EPHE PSL Research University Bordeaux France
| | - Jerome Berge
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
| | - Thomas Tourdias
- CHU de Bordeaux Neuroimagerie diagnostique et thérapeutique Bordeaux France
- INSERM‐U1215 Neurocentre Magendie Bordeaux France
| | - Igor Sibon
- CHU de Bordeaux Unité Neuro‐vasculaire Bordeaux France
- UMR 5287 CNRS Université de Bordeaux EPHE PSL Research University Bordeaux France
- Université de Bordeaux Bordeaux France
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Salem GM, El-Sheik WM, El-Shanawany BG, Afifi KH. Low versus standard dose intravenous alteplase in the treatment of acute ischemic stroke in Egyptian patients. ACTA ACUST UNITED AC 2021; 26:179-185. [PMID: 33814371 PMCID: PMC8024130 DOI: 10.17712/nsj.2021.2.20200148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/30/2020] [Indexed: 01/01/2023]
Abstract
Objectives: To assess low dose altepase outcome and safety in comparison with a standard-dose regimen for acute ischemic stroke treatment in Egyptian patients. Materials: An observational prospective cohort non-randomized single blinded study was carried out during the period from November 2017 to December 2018. Eighty Egyptian acute ischemic stroke patients, all eligible for intravenous alteplase, were subdivided into 2 groups (40 patients in each group). Patients were thrombolysed at a dose of 0.6 mg/kg in the first group and 0.9 mg/kg in the second group. Both groups were compared in regard to safety and outcome. Safety was expressed by the rate of symptomatic intracranial hemorrhage (SICH) and 3 months mortality, while outcome was expressed by favorable outcomes at three months (modified Rankin Scale [mRS] of 0 to 2). Results: In the first group, 69.2% (n=27) achieved favorable outcomes at 90 days compared with 64.1% (n=25) in the second group (p=0.631). Ninety-day mortality was 5% (n=2) in the first group versus 2.5% (n=1) in the second group (p=0.556). Symptomatic intracranial hemorrhage was noted in 3 patients in the second group and zero patients in the first group (p=0.077). Conclusion: Low-dose alteplase could be a practical alternative for Egyptian populations with acute ischemic stroke especially in 3 to 4.5 hours window.
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Affiliation(s)
- Gelan M Salem
- From the Neuro-Psychiatry Department (Salem, El-Sheik, Afifi), Menoufia University, Menoufia; from the Mataria Teaching Hospital (El-shanawany), Mataria, Egypt
| | - Wafik M El-Sheik
- From the Neuro-Psychiatry Department (Salem, El-Sheik, Afifi), Menoufia University, Menoufia; from the Mataria Teaching Hospital (El-shanawany), Mataria, Egypt
| | - Basma G El-Shanawany
- From the Neuro-Psychiatry Department (Salem, El-Sheik, Afifi), Menoufia University, Menoufia; from the Mataria Teaching Hospital (El-shanawany), Mataria, Egypt
| | - Khaled H Afifi
- From the Neuro-Psychiatry Department (Salem, El-Sheik, Afifi), Menoufia University, Menoufia; from the Mataria Teaching Hospital (El-shanawany), Mataria, Egypt
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5
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Zhu X, Cao G. Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2020; 26:1076029620942594. [PMID: 32727211 PMCID: PMC7394033 DOI: 10.1177/1076029620942594] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same. Methods: We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I2. Results: In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention. Conclusions: In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.
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Affiliation(s)
- Xiaolin Zhu
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China.,Both the authors contributed equally to this work
| | - Genmao Cao
- Department of Vascular Surgery, Second Hospital of Shanxi Medical University, Taiyuan, People's Republic of China.,Both the authors contributed equally to this work
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6
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Dong Y, Han Y, Shen H, Wang Y, Ma F, Li H, Wang Y, Dong Q. Who may benefit from lower dosages of intravenous tissue plasminogen activator? Results from a cluster data analysis. Stroke Vasc Neurol 2020; 5:348-352. [PMID: 32611728 PMCID: PMC7804063 DOI: 10.1136/svn-2020-000388] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 01/05/2023] Open
Abstract
Background The risk of symptomatic intracranial haemorrhage (sICH) after thrombolysis is low but severe. Lower dose of alteplase may reduce the risk of sICH. We aim to identify subsets of patients who could benefit from lower dose of alteplase compared with standard dose. Methods Data from two observational registries were pooled together. A total of 3479 patients who had acute ischaemic stroke were entered into the interaction tree model. The response variable was the rate of sICH per the definition of the National Institute of Neurological Disorders and Stroke Study. Clinical improvement was measured by the National Institutes of Health Stroke Scale (NIHSS) and defined as NIHSS 0 or 1 or an improvement of more than 4 points (within 7 days or at discharge). Rare event logistic regression was performed to analyse the OR of safety outcome. Results To optimise the interaction effect between tissue plasminogen activator (tPA) dosage (standard/lower) and patient subgroups, three subgroups based on the severity of stroke were identified: (1) NIHSS ≤4, (2) NIHSS between 5 and 14, and (3) NIHSS ≥15. The estimated difference of OR of having sICH was 2.71 (95% CI 0.80 to 7.69, p=0.10) for mild, 0.13 (95% CI 0.02 to 0.68, p=0.01) for moderate, and 0.65 (95% CI 0.19 to 2.55, p=0.52) for severe, respectively. In addition, patients who had moderate stroke treated with lower dose had comparable efficacy outcome (OR 1.23, 95% CI 0.71 to 2.13, p=0.45). Conclusion Our analysis demonstrated that in patients who had moderate stroke, lower doses of alteplase are associated with significant sICH reduction and non-inferior performance in efficacy, compared with those in the standard dose group. Trial registration number The TIMS-China was a national prospective stroke registry on thrombolytic therapy using intravenous tPA in patients who had acute ischaemic stroke. The results were initially published in 2012 without a clinical trial registration number. The Shanghai Stroke Service System was registered at www.clinicaltrial.gov (NCT02735226).
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Affiliation(s)
- Yi Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, Shanghai, China
| | - Ye Han
- Department of Business Administration, College of Business, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Haipeng Shen
- Faculty of Business and Economics, University of Hong Kong, Hong Kong, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Frank Ma
- Medical Research Center, DotHealth, Shanghai, China
| | - Hao Li
- Big data and AI dempartment, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, Shanghai, China
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7
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Wong YS, Sung SF, Wu CS, Hsu YC, Su YH, Hung LC, Ong CT. The Impact of Loading Dose on Outcome in Stroke Patients Receiving Low-Dose Tissue Plasminogen Activator Thrombolytic Therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:257-263. [PMID: 32021109 PMCID: PMC6974114 DOI: 10.2147/dddt.s235388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022]
Abstract
Background Intravenous tissue plasminogen activator (tPA) (0.9 mg/kg, maximum 90 mg) with a bolus of 10% of the total dose given within 1–2 mins is the standard therapy for patients receiving thrombolytic therapy. Low-dose (0.6 mg/kg) tPA is also approved for thrombolytic therapy for ischemic stroke patients. Low-dose tPA is associated with a low bolus dose. It is unknown whether increasing the bolus dose in patients receiving low-dose tPA thrombolysis may improve outcomes or increase the risk of hemorrhagic transformation (HT). Aim This study investigated the impact of the bolus dose on the outcome in ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Methods In this retrospective, observational study, we enrolled 214 ischemic stroke patients receiving low-dose tPA thrombolytic therapy. Of these 214 patients, 107 patients received 10% of the total dose as a bolus dose, and 107 patients received 15% of the total dose as a bolus dose. The National Institutes of Health Stroke Score (NIHSS) were evaluated before tPA infusion, 24 h after thrombolytic therapy, and at discharge. Stroke severity was categorized as mild (0–5), moderate (6–14), severe (15–24), or very severe (≥25). Neurological improvement (NI) was defined as an improvement of 6 or more points in the NIHSS, and no response (NR) was defined as an increase in the NIHSS of ≤4 points or a decrease ≤6 points. Neurological deterioration (ND) was defined as an increase in the NIHSS >4 points. A good outcome was defined as a modified Ranking Score (mRS) of 0 or 1. We compared the NI, NR, and ND rates at 24 hrs after thrombolytic therapy and discharge between the 15% and 10% bolus dose groups. Results In patients with mild and moderate stroke, there was no significant difference in the NI, NR, ND, and HT rates and 6-month outcomes between the 15% and 10% bolus groups. In patients with severe and very severe stroke, outcomes at 6 months were significantly better in the 15% bolus group than in the 10% bolus group. The factors affecting the outcomes of severe and very severe stroke patients are hypertension and bolus dose. Conclusion In severe and very severe stroke patients receiving low-dose tPA thrombolytic therapy, a bolus dose of 15% of the total dose can improve outcomes.
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Affiliation(s)
- Yi-Sin Wong
- Department of Family Medicine, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Sheng-Feng Sung
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chi-Shun Wu
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yung-Chu Hsu
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yu-Hsiang Su
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Ling-Chien Hung
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Cheung-Ter Ong
- Department of Neurology, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
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Wang X, Li J, Moullaali TJ, Lee KJ, Kim BJ, Bae HJ, Wang A, Wang Y, Wang DZ, Wang Y, Kumamoto M, Toyoda K, Koga M, Sato S, Yoshimura S, Sui Y, Xu B, Xiao Y, Lee TH, Liou CW, Lee JD, Peng TI, Huang YC, Paliwal PR, Sharma M, Escabillas C, Navarro JC, Sun MC, Dong Y, Dong Q, Anderson CS, Sharma VK. Low-dose versus standard-dose alteplase in acute ischemic stroke in Asian stroke registries: an individual patient data pooling study. Int J Stroke 2019; 14:670-677. [PMID: 31226919 DOI: 10.1177/1747493019858777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the comparative efficacy and safety of the low-dose versus standard-dose alteplase using real-world acute stroke registry data from Asian countries. METHODS Individual participant data were obtained from nine acute stroke registries from China, Japan, Philippines, Singapore, South Korea, and Taiwan between 2005 and 2018. Inverse probability of treatment weight was used to remove baseline imbalances between those receiving low-dose versus standard-dose alteplase. The primary outcome was death or disability defined by modified Rankin Scale scores of 2 to 6 at 90 days. Secondary outcomes were symptomatic intracerebral hemorrhage and death. Generalized linear mixed models with the individual registry as a random intercept were performed to determine associations of treatment with low-dose alteplase and outcomes. RESULTS Of the 6250 patients (mean age 66 years, 36% women) included in these analyses, 1610 (24%) were treated with low-dose intravenous alteplase. Clinical outcomes for low-dose alteplase were not significantly different to those for standard-dose alteplase, adjusted odds ratios for death or disability: 1.00 (0.85-1.19) and symptomatic intracerebral hemorrhage 0.87 (0.63-1.19), except for lower death with borderline significance, 0.77 (0.59-1.01). CONCLUSIONS The present analyses of real-world Asian acute stroke registry data suggest that low-dose intravenous alteplase has overall comparable efficacy for functional recovery and greater potential safety in terms of reduced mortality, to standard-dose alteplase for the treatment of acute ischemic stroke.
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Affiliation(s)
- Xia Wang
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Jingwei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China.,Department of Cardiology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Tom J Moullaali
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Keon-Joo Lee
- The Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Beom Joon Kim
- The Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Hee-Joon Bae
- The Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - David Z Wang
- College of Medicine, University of Illinois, Peoria, IL, USA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Masaya Kumamoto
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Yi Sui
- Shenyang First People's Hospital, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang Clinical Research Center for Neurological Disorders, Shenyang, China
| | - Bing Xu
- Shenyang First People's Hospital, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang Clinical Research Center for Neurological Disorders, Shenyang, China
| | - Ying Xiao
- Shenyang First People's Hospital, Shenyang Medical College Affiliated Shenyang Brain Hospital, Shenyang Brain Institute, Shenyang Clinical Research Center for Neurological Disorders, Shenyang, China
| | - Tsong-Hai Lee
- Department of Neurology, Chang Gung Memorial Hospital, Linkou Medical Center and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Wei Liou
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tsung-I Peng
- Department of Neurology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yen-Chu Huang
- Department of Neurology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | | | - Manasi Sharma
- Division of Neurology, National University Hospital, Singapore
| | - Cyrus Escabillas
- Stroke Services, Department of Neurology, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Jose C Navarro
- Stroke Services, Department of Neurology, Jose R. Reyes Memorial Medical Center, Manila, Philippines
| | - Mu-Chien Sun
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yi Dong
- Department of Neurology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Craig S Anderson
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia.,The George Institute China, Peking University Health Science Center, Beijing, China
| | - Vijay K Sharma
- Division of Neurology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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9
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Cheng JW, Zhang XJ, Cheng LS, Li GY, Zhang LJ, Ji KX, Zhao Q, Bai Y. Low-Dose Tissue Plasminogen Activator in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2018; 27:381-390. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/23/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022] Open
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10
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Zhao G, Huang T, Zheng M, Cui Y, Liu Y, Cheng Z, Wang Z. Comparative Analysis on Low- and Standard-Dose Regimes of Alteplase Thrombolytic Therapy for Acute Ischemic Stroke: Efficacy and Safety. Eur Neurol 2017; 79:68-73. [DOI: 10.1159/000485460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/14/2017] [Indexed: 11/19/2022]
Abstract
Objective: This study analyzed the efficacy and safety of low-dose and standard-dose alteplase intravenous thrombolytic therapy for acute ischemic stroke (AIS). Methods: Patients with AIS who underwent intravenous alteplase thrombolysis from July 2012 to December 2016 were retrospectively analyzed and correspondingly divided into low-dose (0.6–0.89 mg/kg) group and standard-dose group (0.9 mg/kg) according to alteplase dosage. The clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. The safety index was the mortality at 90 days after onset and the incidence of symptomatic intracranial hemorrhage (SICH) within 7 days. Results: A total of 1,486 patients were included (1,115 cases in low-dose group and 371 cases in standard-dose group). There were no significant differences in baseline data between the 2 groups. As mRS, good outcome rate as well as mortality rate in both groups had no significant difference (36.1 vs. 37.6%; χ2 = 10.882, p = 0.890; 5.5 vs. 7.3%; χ2 = 2.163, p = 0.076), but the incidence of SICH in low-dose group was significantly lower than that of the standard-dose group (2.2 vs. 5.9%; χ2 = 3.157, p = 0.001). Conclusion: The efficacy of low-dose alteplase intravenous thrombolytic therapy for AIS was equivalent to the standard-dose regimen but with higher safety.
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11
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Liu H, Zheng H, Cao Y, Pan Y, Wang D, Zhang R, You S, Zhang X, Li S, Tong X, Liu CF, Wang Y. Low- versus Standard-Dose Intravenous Tissue-Type Plasminogen Activator for Acute Ischemic Stroke: An Updated Meta-Analysis. J Stroke Cerebrovasc Dis 2017; 27:988-997. [PMID: 29224744 DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/02/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We performed a meta-analysis to compare the efficacy and safety between low- and standard-dose intravenous (IV) tissue-type plasminogen activator (tPA) for acute ischemic stroke (AIS) patients within 4.5 hours of symptom onset. METHODS We searched PubMed and EMBASE for relevant studies from inception to June1, 2017. Cohort or randomized controlled studies for AIS within 4.5 hours of symptom onset with comparison between low-dose and standard-dose tPA were included. The primary efficacy end point was favorable functional outcome (modified Rankin scale scores [mRS] of 0-1) at 90 days. The primary safety end point was the incidence rate of symptomatic intracerebral hemorrhage (sICH). The secondary end points were independent functional outcome (mRS scores of 0-2) and mortality. RESULTS A total of 11 studies were pooled in this meta-analysis. The low-dose strategy appeared to be as effective as standard-dose tPA (43.4% versus 45.4%; odds ratio [OR] = 0.93, 95% confidence interval [CI]: 0.78-1.10; P = .38) in primary efficacy outcome. The secondary efficacy outcome produced similar results (57.3% versus 57.0%; OR = 0.95, 95% CI: 0.86-1.05; P= .33). There was no evidence of statistical difference for sICH (4.2% versus 4.9%; OR = 1.02 [0.66-1.55]; P = .94) and mortality (9.0% versus 10.6%; OR = 0.99 [0.74-1.31]; P = .92) at 90 days between low- and standard-dose therapy. In a subgroup analysis by ethnicity, there was no significant difference between patients of Asian and non-Asian descent for any of the end points. CONCLUSIONS This study showed that AIS patients receiving low-dose IV-tPA had comparably efficacy and safety to those receiving standard-dose IV-tPA. However, the effect is especially pronounced within the Asian population, which limits the generalizability of these results.
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Affiliation(s)
- Huihui Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, Suzhou, China.
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - David Wang
- Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St. Francis Healthcare System, University of Illinois College of Medicine, Peoria, Illinois
| | - Runhua Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuya Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xu Tong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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12
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Wang X, Robinson TG, Lee TH, Li Q, Arima H, Bath PM, Billot L, Broderick J, Demchuk AM, Donnan G, Kim JS, Lavados P, Lindley RI, Martins SO, Olavarria VV, Pandian JD, Parsons MW, Pontes-Neto OM, Ricci S, Sharma VK, Thang NH, Wang JG, Woodward M, Anderson CS, Chalmers J. Low-Dose vs Standard-Dose Alteplase for Patients With Acute Ischemic Stroke: Secondary Analysis of the ENCHANTED Randomized Clinical Trial. JAMA Neurol 2017; 74:1328-1335. [PMID: 28973174 DOI: 10.1001/jamaneurol.2017.2286] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A lower dose of intravenous alteplase appears to be a safer treatment option than the standard dose, reducing the risk of symptomatic intracerebral hemorrhage. There is uncertainty, however, over how this effect translates into an overall clinical benefit for patients with acute ischemic stroke (AIS). Objective To assess whether older, Asian, or severely affected patients with AIS who are considered at high risk of thrombolysis may benefit more from low-dose rather than standard-dose alteplase treatment. Design, Setting, and Participants This study is a prespecified secondary analysis of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), an international, randomized, open-label, blinded, end-point clinical trial of low-dose vs standard-dose intravenous alteplase for patients with AIS. From March 1, 2012, to August 31, 2015, a total of 3310 patients who had a clinical diagnosis of AIS as confirmed by brain imaging and who fulfilled the local criteria for thrombolysis treatment were included in the alteplase-dose arms. Patients were randomly assigned to receive low-dose (0.6 mg/kg; 15% as bolus and 85% as infusion over 1 hour) or standard-dose (0.9 mg/kg; 10% as bolus and 90% as infusion over 1 hour) alteplase. Of the 3310 randomized patients, 13 patients were excluded for missing consent, mistaken randomization, and duplicate randomization numbers. This secondary analysis was conducted between May 1, 2016, and April 28, 2017. Main Outcomes and Measures The primary end point was a poor outcome defined by the combination of death and any disability as scored by the modified Rankin Scale (scores range from 2 to 6, with the highest score indicating death) at 90 days. Results Of the 3297 patients included in the analysis, 1248 (37.9%) were women, and the mean (SD) age was 67 (13) years. No significant differences in the treatment effects were observed between low- and standard-dose alteplase for poor outcomes (death or disability) by age, ethnicity, or severity (all P > .37 for interaction). Similarly, the treatment effects of low- vs standard-dose alteplase on function outcome (ordinal shift of the modified Rankin Scale) in Asians (odds ratio, 1.05; 95% CI, 0.90-1.22) was consistent with non-Asians (odds ratio, 0.93; 95% CI, 0.76-1.14) (P = .32 for interaction). There were generally consistent reductions in rates of symptomatic intracerebral hemorrhage with low-dose alteplase, although this reduction was not statistically significant by age, ethnicity, or severity. Conclusions and Relevance This analysis found that the effects of low-dose alteplase were not clearly superior to the effects of standard-dose alteplase on death or disability in key demographic subgroups of patients with AIS. Further investigation is required to identify patients with AIS who may benefit from low-dose alteplase. Trial Registration clinicaltrials.gov Identifier: NCT01422616.
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Unit, University of Leicester, Leicester, England
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Hisatomi Arima
- Department of Public Health, Fukuoka University, Fukuoka, Japan
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, England
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, Ohio
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Geoffrey Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Jong S Kim
- Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Pablo Lavados
- Departamento de Neurología, Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile.,Departamento de Ciencias Neurológicas, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Richard I Lindley
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sheila O Martins
- Stroke Division of Neurology Service, Hospital de Clinicas de Porto Alegre, University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Veronica V Olavarria
- Departamento de Neurología, Clinica Alemana de Santiago, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Jeyaraj D Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Octavio M Pontes-Neto
- Department of Neurosciences and Behavioural Sciences, Ribeirao Preto School of Medicine, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Stefano Ricci
- Uo Neurologia, USL Umbria 1, Sedi di Citta di Castello e Branca, Italy
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University Hospital, Singapore.,Division of Neurology, National University Hospital, Singapore
| | - Nguyen H Thang
- Department of Cerebrovascular Disease, The People's 115 Hospital, Ho Chi Minh City, Vietnam
| | - Ji-Guang Wang
- The Shanghai Institute for Hypertension, Shanghai, China.,Rui Jin Hospital, Shanghai, China.,Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, University of Oxford, Oxford, England
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The George Institute China at Peking University Health Science Center, Beijing, China
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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13
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Tan G, Wang H, Chen S, Chen D, Zhu L, Xu D, Zhang Y, Liu L. Efficacy and safety of low dose alteplase for intravenous thrombolysis in Asian stroke patients: a meta-analysis. Sci Rep 2017; 7:16076. [PMID: 29167555 PMCID: PMC5700077 DOI: 10.1038/s41598-017-16355-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/10/2017] [Indexed: 02/05/2023] Open
Abstract
Whether low dose alteplase is comparable to standard dose in efficacy and safety for intravenous thrombolysis (IVT) in Asian stroke patients remains unverified. PubMed, EMBASE, and Cochrane Library Database from the beginning to June 30, 2017 were searched. IVT efficacy was measured by favorable outcome (modified Rankin Scale scores of 0–1) at 3 months, and safety measured by mortality within 3 months and symptomatic intracerebral hemorrhage (SICH). Pooled estimates were conducted using fixed- or random-effects model depending on heterogeneity. For SICH, studies were pooled separately according to different definitions. Twelve studies involving 7,905 participants were included. No association was found between alteplase dose and favorable outcome (OR = 0.94, 95% CI 0.78–1.14, P = 0.5; heterogeneity: Phetero = 0.01, I2 = 57.3%) and mortality (OR = 0.87, 95% CI 0.74–1.02, P = 0.08; Phetero = 0.83, I2 = 0) using random- and fixed-effects models, respectively. Low dose alteplase was associated with lower SICH as defined by the National Institute of Neurological Disorders and Stroke study (OR = 0.79, 95% CI 0.64–0.99, P = 0.04; Phetero = 0.57, I2 = 0) using fixed-effects model. Subgroup and sensitivity analysis could change the results significantly. Current limited evidence was insufficient to support the speculation that low dose alteplase was comparable to standard dose in thrombolytic efficacy and safety in Asian stroke patients.
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Affiliation(s)
- Ge Tan
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Haijiao Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Sihan Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Lina Zhu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Da Xu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Yu Zhang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China.
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