1
|
Lima Neto AC, Bittar RSM. Vascular vertigo and dizziness: managing and treating outpatients. Braz J Otorhinolaryngol 2024; 90:101453. [PMID: 38991403 PMCID: PMC11295563 DOI: 10.1016/j.bjorl.2024.101453] [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: 08/15/2023] [Revised: 02/14/2024] [Accepted: 05/23/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVE Due the lack of data on the treatment of Vascular Vertigo and Dizziness, this study aimed to report how we managed and treated those outpatients according to the recently introduced American Heart Association and Stroke Association guidelines. METHODS We conducted a longitudinal case series from May 2022 to February 2023. We included patients who met the Bárány Society's Vascular Vertigo and Dizziness classification and were eligible for therapy in accordance with the American Heart Association and Stroke Association guidelines, featuring aspects of the stroke group and transient attack group. RESULTS Overall, 41 patients (51.2% female; median age 72 years) were enrolled; 10 (24.3%) had ischemic strokes, 30 (73.1%) had transient ischemic attack, and 1 (2.4%) had a probable isolated labyrinthine infarction. The patients received dual antiplatelet (48.7%), single antiplatelet therapy (48.7%), and anticoagulant therapy (2.4%). No new crises occurred in 95.2% of the patients, and the transient ischemic attack group showed a significant decrease in discomfort from imbalance on the visual analog scale. CONCLUSIONS Antiplatelets and anticoagulants are safe and effective in treating Vascular Vertigo and Dizziness as they prevent new ischemic events and increase the flow of the posterior circulation, reducing vertigo/dizziness attacks and imbalance complaints. LEVEL OF EVIDENCE: 4
Collapse
Affiliation(s)
- Arlindo Cardoso Lima Neto
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil.
| | - Roseli Saraiva Moreira Bittar
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil
| |
Collapse
|
2
|
Smiley K, Yoo MJ, Long B. Are the HINTS and HINTS Plus Examinations Accurate for Identifying a Central Cause of Acute Vestibular Syndrome? Ann Emerg Med 2024; 84:60-62. [PMID: 38385911 DOI: 10.1016/j.annemergmed.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Kyle Smiley
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Michael Jay Yoo
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| |
Collapse
|
3
|
Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev 2023; 11:CD015089. [PMID: 37916744 PMCID: PMC10620998 DOI: 10.1002/14651858.cd015089.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function. OBJECTIVES To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022. SELECTION CRITERIA We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist. DATA COLLECTION AND ANALYSIS Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome. MAIN RESULTS We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard. AUTHORS' CONCLUSIONS The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.
Collapse
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jestin N Carlson
- Emergency Department, Allegheny Health Network, Erie, Pennsylvania, USA
| |
Collapse
|
4
|
Chen JJ, Zeng BS, Su KP, Wu YC, Tu YK, Stubbs B, Chen TY, Zeng BY, Chen YW, Hsu CW, Tseng PT. Network Meta-analysis of Different Treatments for Vestibular Migraine. CNS Drugs 2023; 37:837-847. [PMID: 37676473 PMCID: PMC10501927 DOI: 10.1007/s40263-023-01037-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Although one of the major presentations of vestibular migraine is dizziness with/without unsteady gait, it is still classified as one of the migraine categories. However, in contrast to ordinary migraine, vestibular migraine patients have distinct characteristics, and the detailed treatment strategy for vestibular migraine is different and more challenging than ordinary migraine treatment. Currently, there is no conclusive evidence regarding its management, including vestibular migraine prophylaxis. AIM The objective of this current network meta-analysis (NMA) was to compare the efficacy and acceptability of individual treatment strategies in patients with vestibular migraine. METHODS The PubMed, Embase, ScienceDirect, ProQuest, Web of Science, ClinicalKey, Cochrane Central, and ClinicalTrials.gov databases were systematically searched for randomized controlled trials (RCTs), with a final literature search date of 30 December 2022. Patients diagnosed with vestibular migraine were included. The PICO of the current study included (1) patients with vestibular migraine; (2) intervention: any active pharmacologic or non-pharmacologic intervention; (3) comparator: placebo-control, active control, or waiting list; and (4) outcome: changes in migraine frequency or severity. This NMA of RCTs of vestibular migraine treatment was conducted using a frequentist model. We arranged inconsistency and similarity tests to re-examine the assumption of NMA, and also conducted a subgroup analysis focusing on RCTs of pharmacological treatment for vestibular migraine management. The primary outcome was changes in the frequency of vestibular migraines, while the secondary outcomes were changes in vestibular migraine severity and acceptability. Acceptability was set as the dropout rate, which was defined as the participant leaving the study before the end of the trial for any reason. Two authors independently evaluated the risk of bias for each domain using the Cochrane risk-of-bias tool. RESULTS Seven randomized controlled trials (N = 828, mean age 37.6 years, 78.4% female) and seven active regimens were included. We determined that only valproic acid (standardized mean difference [SMD] -1.61, 95% confidence interval [CI] -2.69, -0.54), propranolol (SMD -1.36, 95% CI -2.55, -0.17), and venlafaxine (SMD -1.25, 95% CI -2.32, -0.18) were significantly associated with better improvement in vestibular migraine frequency than the placebo/control groups. Furthermore, among all the investigated pharmacologic/non-pharmacologic treatments, valproic acid yielded the greatest decrease in vestibular migraine frequency among all the interventions. In addition, most pharmacologic/non-pharmacologic treatments were associated with similar acceptability (i.e. dropout rate) as those of the placebo/control groups. CONCLUSIONS The current study provides evidence that only valproic acid, propranolol, and venlafaxine might be associated with beneficial efficacy in vestibular migraine treatment. TRIAL REGISTRATION CRD42023388343.
Collapse
Affiliation(s)
- Jiann-Jy Chen
- Department of Otorhinolaryngology, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- Prospect Clinic for Otorhinolaryngology and Neurology, No. 252, Nanzixin Road, Nanzi District, Kaohsiung, 81166, Taiwan
| | - Bing-Syuan Zeng
- Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Kuan-Pin Su
- Department of Psychiatry and Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Yu-Kang Tu
- Institute of Health Data Analytics and Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Positive Ageing Research Institute (PARI), Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, UK
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Bing-Yan Zeng
- Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology and Neurology, No. 252, Nanzixin Road, Nanzi District, Kaohsiung, 81166, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Road, Niaosong District, Kaohsiung, 833401, Taiwan.
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology and Neurology, No. 252, Nanzixin Road, Nanzi District, Kaohsiung, 81166, Taiwan.
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan.
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan.
| |
Collapse
|
5
|
Mantokoudis G, Zwergal A, Heg D, Kerkeni H, Diener S, Kalla R, Korda A, Candreia C, Welge-Lüssen A, Tarnutzer AA. Needs and supporting tools for primary care physicians to improve care of patients with vertigo and dizziness: a national survey. Front Neurol 2023; 14:1254105. [PMID: 37706010 PMCID: PMC10495563 DOI: 10.3389/fneur.2023.1254105] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/14/2023] [Indexed: 09/15/2023] Open
Abstract
Background The diagnostic workup and treatment decisions for vertigo or dizziness in primary care can be challenging due to the broad range of possible causes and limited time and expertise of physicians. This can lead to delays in treatment and unnecessary tests. We aimed to identify the unmet needs of primary care physicians (PCPs) and strategies to improve care for dizzy patients. Materials and methods An online survey was conducted among board-certified PCPs in Switzerland to explore needs in caring for dizzy patients and potential educational approaches. Results Based on responses from 152 participating PCPs, satisfaction and confidence were higher in diagnosing (82%) and treating (76%) acute dizziness compared to episodic/chronic cases (63 and 59%, respectively). Younger PCPs had lower diagnostic yield and confidence. Areas for improvement in specialist interactions included communication between physicians (23%/36%; always/often true), shorter waiting times for consultations (19%/40%), more detailed feedback (36%/35%), and consistent patient back referrals (31%/30%). PCPs expressed interest in hands-on courses, workshops, practical guidelines, web-based algorithms, and digital tools such as printed dizzy diaries and apps for follow-up. Conclusion Enhanced dialog between PCPs and specialists is crucial to address the most common unmet needs. Reducing waiting times for referrals and providing clear instructions to specialists for triage are essential. The findings from this survey will guide the development of tools to improve the diagnosis and treatment of dizzy patients. Younger PCPs, who face higher diagnostic uncertainty, should be prioritized for educational approaches such as hands-on courses, workshops, and practical recommendations.
Collapse
Affiliation(s)
- Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, Munich, Germany
- Department of Neurology, LMU University Hospital, Munich, Germany
| | - Dierik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Hassen Kerkeni
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzie Diener
- Practice Neurology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Roger Kalla
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Candreia
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Antje Welge-Lüssen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander Andrea Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
6
|
Posterior circulation stroke diagnosis in unselected group of acutely dizzy patients. Clin Neurol Neurosurg 2022; 224:107541. [PMID: 36493551 DOI: 10.1016/j.clineuro.2022.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS Diagnostics of a posterior circulation ischemia (POCI) in patients with acute vertigo is a challenging task. Recently, the combination of HINTS (Head Impulse, Nystagmus and Test of Skew) exam and ABCD2 has been recommended to identify stroke in these patients. Until now, studies regarding HINTS have mostly been tested on preselected patient groups and their results are only partially applicable to real clinical practice. AIMS To compare the sensitivity and specificity of HINTS and ABCD2 and their combination in unselected acutely dizzy patients in the emergency department (ED) toward posterior circulation stroke detection. METHODS A prospective cross-sectional monocentric study in ED patients with acute onset of dizziness lasting less than 72 h. Their clinical characteristics, HINTS, vascular risk factors, ABCD2 scores and neuroimaging data were analyzed. RESULTS 140 patients were recruited. Acute stroke was identified by MRI in 39 patients. All patients had central pattern nystagmus, skew deviation or further focal neurological finding. The age (≥60) and arterial hypertension clearly distinguished stroke and non-stroke group (p < 0001). The sensitivity of HINTS, ABCD2 and their combination in the unselected group was high (82,1 - 97,4%), but specificity low. After removing patients with inconclusive diagnosis, including transitory ischemic attack, specificity was much higher and comparable to previously published results. CONCLUSIONS The sensitivity and specificity of HINTS in previously published studies may vary because of their selection criteria. Even though, our study was performed on the unselected patient cohort, combination of HINTS and ABCD2 remained highly sensitive in detecting POCI and outperformed each of these tests alone.
Collapse
|
7
|
Choi JY, Kim S, Boo D, Yoo S, Kim HJ, Kim JY, Lee KJ, Kang J, Kim BJ, Han MK, Bae HJ, Kim JS. Risk of Future Stroke in Patients with a Diagnosis of Peripheral Vertigo in the Emergency Department. Eur J Neurol 2022. [PMID: 36056876 DOI: 10.1111/ene.15543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/05/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND We evaluated the temporal characteristics of stroke risks in the emergency department patients who had a diagnosis of peripheral vertigo. We also attempted to reveal the stroke risk factor among those with peripheral vertigo. METHODS This is a parallel group cohort study in a tertiary referral hospital. After assigning each of matched 4367 patients to the comparative set of peripheral vertigo and appendicitis-ureterolithiasis groups and each of matched 4911 to the comparative set of peripheral vertigo and ischemic stroke groups, we evaluated the relative stroke risk. In addition, to predict the individual stroke risk in patients with peripheral vertigo, any association between the demographic factors and stroke events was evaluated in the peripheral vertigo group. RESULTS The peripheral vertigo group had a higher stroke risk than the appendicitis-ureterolithiasis group (HR=1.73, 95% CI=1.18-2.55) but a lower risk than the ischemic stroke group (HR=0.30, 95% CI=0.24-0.37). The stroke risk of the peripheral vertigo group was just below that of small vessel stroke. The stroke risk of the peripheral vertigo group differed markedly by time: higher within seven days, moderate between seven days and one year, and diminished thereafter. Old age (>65), male gender, and diabetes mellitus were the risk factors for stroke in the peripheral vertigo group. CONCLUSION Patients with a diagnosis of peripheral vertigo in the ED showed a moderate future stroke risk so that requires a stroke preventive strategy tailored to the timing of symptom onset and individual risk.
Collapse
Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok Kim
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dachung Boo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sooyoung Yoo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|