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EEG spectral exponent as a synthetic index for the longitudinal assessment of stroke recovery. Clin Neurophysiol 2022; 137:92-101. [PMID: 35303540 PMCID: PMC9038588 DOI: 10.1016/j.clinph.2022.02.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/02/2022] [Accepted: 02/22/2022] [Indexed: 12/20/2022]
Abstract
The Spectral Exponent (SE) indexes power-law features of the resting EEG in stroke patients. SE is consistently steeper in the affected hemisphere of patients after middle cerebral artery stroke. SE is linked to clinical status and seems to be a good predictor of clinical outcome.
Objective Quantitative Electroencephalography (qEEG) can capture changes in brain activity following stroke. qEEG metrics traditionally focus on oscillatory activity, however recent findings highlight the importance of aperiodic (power-law) structure in characterizing pathological brain states. We assessed neurophysiological alterations and recovery after mono-hemispheric stroke by means of the Spectral Exponent (SE), a metric that reflects EEG slowing and quantifies the power-law decay of the EEG Power Spectral Density (PSD). Methods Eighteen patients (n = 18) with mild to moderate mono-hemispheric Middle Cerebral Artery (MCA) ischaemic stroke were retrospectively enrolled for this study. Patients underwent EEG recording in the sub-acute phase (T0) and after 2 months of physical rehabilitation (T1). Sixteen healthy controls (HC; n = 16) matched by age and sex were enrolled as a normative group. SE values and narrow-band PSD were estimated for each recording. We compared SE and band-power between patients and HC, and between the affected (AH) and unaffected hemisphere (UH) at T0 and T1 in patients. Results At T0, stroke patients showed significantly more negative SE values than HC (p = 0.003), reflecting broad-band EEG slowing. Most important, in patients SE over the AH was consistently more negative compared to the UH and showed a renormalization at T1. This SE renormalization significantly correlated with National Institute of Health Stroke Scale (NIHSS) improvement (R = 0.63, p = 0.005). Conclusions SE is a reliable readout of the neurophysiological and clinical alterations occurring after an ischaemic cortical lesion. Significance SE promise to be a robust method to monitor and predict patients’ functional outcome.
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Betancur DFA, Tarragó MDGL, Torres ILDS, Fregni F, Caumo W. Central Post-Stroke Pain: An Integrative Review of Somatotopic Damage, Clinical Symptoms, and Neurophysiological Measures. Front Neurol 2021; 12:678198. [PMID: 34484097 PMCID: PMC8416310 DOI: 10.3389/fneur.2021.678198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/02/2021] [Indexed: 01/26/2023] Open
Abstract
Introduction: The physiopathology of central post-stroke pain (CPSP) is poorly understood, which may contribute to the limitations of diagnostic and therapeutic advancements. Thus, the current systematic review was conducted to examine, from an integrated perspective, the cortical neurophysiological changes observed via transcranial magnetic stimulation (TMS), focusing on the structural damage, and clinical symptoms in patients with CPSP. Methods: The literature review included the databases EMBASE, PubMed, and ScienceDirect using the following search terms by MeSH or Entree descriptors: [("Cerebral Stroke") AND ("Pain" OR "Transcranial Magnetic Stimulation") AND ("Transcranial Magnetic Stimulation")] (through September 29, 2020). A total of 297 articles related to CPSP were identified. Of these, only four quantitatively recorded cortical measurements. Results: We found four studies with different methodologies and results of the TMS measures. According to the National Institutes of Health (NIH) guidelines, two studies had low methodological quality and the other two studies had satisfactory methodological quality. The four studies compared the motor threshold (MT) of the stroke-affected hemisphere with the unaffected hemisphere or with healthy controls. Two studies assessed other cortical excitability measures, such as cortical silent period (CSP), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF). The main limitations in the interpretation of the results were the heterogeneity in parameter measurements, unknown cortical excitability measures as potential prognostic markers, the lack of a control group without pain, and the absence of consistent and validated diagnosis criteria. Conclusion: Despite the limited number of studies that prevented us from conducting a meta-analysis, the dataset of this systematic review provides evidence to improve the understanding of CPSP physiopathology. Additionally, these studies support the construction of a framework for diagnosis and will help improve the methodological quality of future research in somatosensory sequelae following stroke. Furthermore, they offer a way to integrate dysfunctional neuroplasticity markers that are indirectly assessed by neurophysiological measures with their correlated clinical symptoms.
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Affiliation(s)
- Daniel Fernando Arias Betancur
- Graduate Program in Medical Sciences, School of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratory of Pain & Neuromodulation, Clinical Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | | | - Iraci Lucena da Silva Torres
- Graduate Program in Medical Sciences, School of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Pharmacology of Pain and Neuromodulation: Pre-clinical Investigations Research Group, Federal University of Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation and Center for Clinical Research Learning, Physics, and Rehabilitation Department, Spaulding Rehabilitation Hospital, Boston, MA, United States
| | - Wolnei Caumo
- Graduate Program in Medical Sciences, School of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratory of Pain & Neuromodulation, Clinical Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pain and Palliative Care Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Department of Surgery, School of Medicine, Federal University of Rio Grande Do Sul (UFRGS), Porto Alegre, Brazil
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Corp DT, Bereznicki HGK, Clark GM, Youssef GJ, Fried PJ, Jannati A, Davies CB, Gomes-Osman J, Kirkovski M, Albein-Urios N, Fitzgerald PB, Koch G, Di Lazzaro V, Pascual-Leone A, Enticott PG. Large-scale analysis of interindividual variability in single and paired-pulse TMS data. Clin Neurophysiol 2021; 132:2639-2653. [PMID: 34344609 DOI: 10.1016/j.clinph.2021.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE This study brought together over 60 transcranial magnetic stimulation (TMS) researchers to create the largest known sample of individual participant single and paired-pulse TMS data to date, enabling a more comprehensive evaluation of factors driving response variability. METHODS Authors of previously published studies were contacted and asked to share deidentified individual TMS data. Mixed-effects regression investigated a range of individual and study level variables for their contribution to variability in response to single and paired-pulse TMS data. RESULTS 687 healthy participant's data were pooled across 35 studies. Target muscle, pulse waveform, neuronavigation use, and TMS machine significantly predicted an individual's single-pulse TMS amplitude. Baseline motor evoked potential amplitude, motor cortex hemisphere, and motor threshold (MT) significantly predicted short-interval intracortical inhibition response. Baseline motor evoked potential amplitude, test stimulus intensity, interstimulus interval, and MT significantly predicted intracortical facilitation response. Age, hemisphere, and TMS machine significantly predicted MT. CONCLUSIONS This large-scale analysis has identified a number of factors influencing participants' responses to single and paired-pulse TMS. We provide specific recommendations to minimise interindividual variability in single and paired-pulse TMS data. SIGNIFICANCE This study has used large-scale analyses to give clarity to factors driving variance in TMS data. We hope that this ongoing collaborative approach will increase standardisation of methods and thus the utility of single and paired-pulse TMS.
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Affiliation(s)
- Daniel T Corp
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia; Berenson-Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Hannah G K Bereznicki
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - Gillian M Clark
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - George J Youssef
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Australia
| | - Peter J Fried
- Berenson-Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ali Jannati
- Berenson-Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Neuromodulation Program and Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Charlotte B Davies
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - Joyce Gomes-Osman
- Berenson-Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Physical Therapy, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Melissa Kirkovski
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - Natalia Albein-Urios
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
| | - Paul B Fitzgerald
- Monash Alfred Psychiatry Research Centre, Central Clinical School, The Alfred and Monash University, Melbourne, Australia; Epworth Centre for Innovation in Mental Health, Epworth HealthCare and Central Clinical School, Melbourne, Australia
| | - Giacomo Koch
- Non-invasive Brain Stimulation Unit, Department of Clinical and Behavioral Neurology, IRCCS Santa Lucia Foundation, Rome, Italy; Department of Biomedical and Specialty Surgical Sciences, Section of Human Physiology, University of Ferrara, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology and Neurobiology, Università Campus Bio-Medico, Rome, Italy
| | - Alvaro Pascual-Leone
- Hinda and Arthur Marcus Institute for Aging Research and Deanna and Sidney Wolk Center for Memory Health, Hebrew SeniorLife, Boston, MA, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA; Guttmann Brain Health Institute, Institut Guttmann de Neurorehabilitació, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Peter G Enticott
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Geelong, Australia
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León Ruiz M, Rodríguez Sarasa M, Sanjuán Rodríguez L, Benito-León J, García-Albea Ristol E, Arce Arce S. Evidencias actuales sobre la estimulación magnética transcraneal y su utilidad potencial en la neurorrehabilitación postictus: Ampliando horizontes en el tratamiento de la enfermedad cerebrovascular. Neurologia 2018; 33:459-472. [DOI: 10.1016/j.nrl.2016.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 03/07/2016] [Accepted: 03/08/2016] [Indexed: 12/17/2022] Open
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León Ruiz M, Rodríguez Sarasa M, Sanjuán Rodríguez L, Benito-León J, García-Albea Ristol E, Arce Arce S. Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation: Opening new doors to the treatment of cerebrovascular disease. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Han SY, Hong ZY, Xie YH, Zhao Y, Xu X. Therapeutic effect of Chinese herbal medicines for post stroke recovery: A traditional and network meta-analysis. Medicine (Baltimore) 2017; 96:e8830. [PMID: 29245245 PMCID: PMC5728860 DOI: 10.1097/md.0000000000008830] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 08/05/2017] [Accepted: 11/01/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Stroke is a condition with high morbidity and mortality, and 75% of stroke survivors lose their ability to work. Stroke is a burden to the family and society. The purpose of this study was to evaluate the effectiveness of Chinese herbal patent medicines in the treatment of patients after the acute phase of a stroke. METHODS We searched the following databases through August 2016: PubMed, Embase, Cochrane library, China Knowledge Resource Integrated Database (CNKI), China Science Periodical Database (CSPD), and China Biology Medicine disc (CBMdisc) for studies that evaluated Chinese herbal patent medicines for post stroke recovery. A random-effect model was used to pool therapeutic effects of Chinese herbal patent medicines on stroke recovery. Network meta-analysis was used to rank the treatment for each Chinese herbal patent medicine. RESULTS In our meta-analysis, we evaluated 28 trials that included 2780 patients. Chinese herbal patent medicines were effective in promoting recovery after stroke (OR, 3.03; 95% CI: 2.53-3.64; P < .001). Chinese herbal patent medicines significantly improved neurological function defect scores when compared with the controls (standard mean difference [SMD], -0.89; 95% CI, -1.44 to -0.35; P = .001). Chinese herbal patent medicines significantly improved the Barthel index (SMD, 0.73; 95% CI, 0.53-0.94; P < .001) and the Fugl-Meyer assessment scores (SMD, 0.60; 95% CI, 0.34-0.86; P < .001). In the network analysis, MLC601, Shuxuetong, and BuchangNaoxintong were most likely to improve stroke recovery in patients without acupuncture. Additionally, Mailuoning, Xuesaitong, BuchangNaoxintong were the patented Chinese herbal medicines most likely to improve stroke recovery when combined with acupuncture. CONCLUSIONS Our research suggests that the Chinese herbal patent medicines were effective for stroke recovery. The most effective treatments for stroke recovery were MLC601, Shuxuetong, and BuchangNaoxintong. However, to clarify the specific effective ingredients of Chinese herbal medicines, a well-designed study is warranted.
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McDonnell MN, Stinear CM. TMS measures of motor cortex function after stroke: A meta-analysis. Brain Stimul 2017; 10:721-734. [DOI: 10.1016/j.brs.2017.03.008] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 01/27/2017] [Accepted: 03/20/2017] [Indexed: 01/05/2023] Open
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Julkunen P, Määttä S, Säisänen L, Kallioniemi E, Könönen M, Jäkälä P, Vanninen R, Vaalto S. Functional and structural cortical characteristics after restricted focal motor cortical infarction evaluated at chronic stage - Indications from a preliminary study. Clin Neurophysiol 2016; 127:2775-2784. [PMID: 27417053 DOI: 10.1016/j.clinph.2016.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 05/04/2016] [Accepted: 05/10/2016] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the inter-hemispheric differences in neuronal function and structure of the motor cortex in a small group of chronic stroke patients having suffered a restricted ischemic lesion affecting hand motor representation. GABAergic intracortical inhibition, known to be affected by stroke lesion, was also investigated. METHODS Eight patients exhibiting little or no motor impairment were studied using transcranial magnetic stimulation (TMS) and diffusion weighted imaging (DWI) >15months from diagnosis. Resting motor threshold (MT) for 50μV and 2mV motor evoked potentials, and short-interval intracortical inhibition (SICI) were measured from hand muscles. Apparent diffusion coefficients (ADCs) were analyzed from the DWI for the primary motor cortex (M1), the supplementary motor area (SMA) and thalamus for reflecting changes in neuronal organization. RESULTS The MTs did not differ between the affected (AH) and unaffected hemisphere (UH) in 50μV responses, while the MTs for 2mV responses were higher (p=0.018) in AH. SICI was weakened in AH (p=0.008). ADCs were higher in the affected M1 compared to the unaffected M1 (p=0.018) while there were no inter-hemispheric differences in SMA or thalamus. CONCLUSIONS Inter-hemispheric asymmetry and neuronal organization demonstrated abnormalities in the M1. However, no confident inference can be made whether the observed alterations in neurophysiological and imaging measures have causal role for motor rehabilitation in these patients. SIGNIFICANCE Neurophysiological changes persist and are detectable using TMS years after stroke even though clinical symptoms have normalized.
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Affiliation(s)
- Petro Julkunen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Applied Physics, University of Eastern Finland, Kuopio, Finland.
| | - Sara Määttä
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Neurophysiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Laura Säisänen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Neurophysiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Elisa Kallioniemi
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Applied Physics, University of Eastern Finland, Kuopio, Finland
| | - Mervi Könönen
- Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- Department of Neurology, Kuopio University Hospital, Kuopio, Finland; Department of Neurology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland; Department of Clinical Radiology, Institute of Clinical Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Selja Vaalto
- Department of Clinical Neurophysiology, Helsinki University Hospital, Helsinki, Finland; Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
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Blesneag AV, Slăvoacă DF, Popa L, Stan AD, Jemna N, Isai Moldovan F, Mureșanu DF. Low-frequency rTMS in patients with subacute ischemic stroke: clinical evaluation of short and long-term outcomes and neurophysiological assessment of cortical excitability. J Med Life 2015; 8:378-87. [PMID: 26351545 PMCID: PMC4556924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 06/10/2015] [Indexed: 11/21/2022] Open
Abstract
RATIONALE Repetitive transcranial magnetic stimulation (rTMS) is used alone or in combination with physiotherapy for rehabilitation of stroke patients. TMS mapping can also quantify the excitability of the motor area in both the ipsilesional (IL) and contralateral (CL) hemisphere. OBJECTIVE This study is the first to measure the dynamics of cortical excitability by TMS mapping before and after treatment with low-frequency (LF) rTMS in the contralesional hemisphere at three different timepoints. Furthermore, the patients were clinically evaluated during the same visit as the mapping to establish both short and long-term outcomes after rTMS treatment. METHODS AND RESULTS A total of 16 participants with acute ischemic stroke were assessed 10 days post-stroke by TMS mapping. The patients were randomized into two equal groups: a real rTMS group and a sham group. The rTMS group received LF-rTMS to the contralesional hemisphere for 10 days, starting on the first day after the first mapping. Each subject was also evaluated by mapping on days 45 and 90 after stroke onset. The primary clinical outcome measured was the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) on days 10, 45 and 90 post-stroke. At 10 days after stroke onset, both groups presented low excitability in the lesion side and high excitability in the non-affected side. In the real rTMS group, at 45 days after stroke, a downward trend in the excitability of the contralesional hemisphere and an upward trend in the excitability of the lesioned side were observed. At 90 days after stroke, a tendency toward balanced excitability between both hemispheres was observed. In the sham group, at both 45 and 90 days, we observed increased excitability in the non-affected side compared to the side with the lesioned motor area. At 45 days, the real rTMS group demonstrated a better recovery of the upper limb motor function than the sham group, but at 90 days, there was no significant difference between the two groups. DISCUSSION These results demonstrated that LF-rTMS treatment enhances rebalance of the excitability patterns in both hemispheres and led us to question the "one size fits all" approach widely used in rTMS interventions. ABBREVIATIONS Amax = maximum amplitude, Amean = AM = averaged amplitude, APB = abductor pollicis brevis, CL = contralesional, DTI = diffusion tensor imaging, EEG = electroencephalography, EMG = electromyography, FMA-UE = Fugl-Meyer Assessment for Upper Extremity, HS = hot spot, IHC = interhemispheric functional connectivity, IL = ipsilesional, LF-rTMS = low-frequency repetitive transcranial magnetic stimulation, MCA = middle cerebral artery, MEP(s) = motor evoked potential(s), NIBS = non-invasive brain stimulation, rMT = resting motor threshold, RP = responsive points, rTMS = repetitive transcranial magnetic stimulation, TMS = transcranial magnetic stimulation.
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Affiliation(s)
- AV Blesneag
- Department of Clinical Neurosciences, ‘‘Iuliu Hațieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
,‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - DF Slăvoacă
- Department of Clinical Neurosciences, ‘‘Iuliu Hațieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
,‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - L Popa
- Department of Clinical Neurosciences, ‘‘Iuliu Hațieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
,‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - AD Stan
- Department of Clinical Neurosciences, ‘‘Iuliu Hațieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
,‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - N Jemna
- County Emergency Hospital, Cluj-Napoca, Romania
| | - F Isai Moldovan
- ‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - DF Mureșanu
- Department of Clinical Neurosciences, ‘‘Iuliu Hațieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania
,‘‘RoNeuro’’ Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
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