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Lee M, Park SH, Kim YJ, Bae JS, Lee JH, Lee SH, Kim C, Lee K, Kim Y. Impact of Systolic Blood Viscosity on Deep White Matter Hyperintensities in Patients With Acute Ischemic Stroke. J Am Heart Assoc 2024; 13:e034162. [PMID: 39041635 DOI: 10.1161/jaha.123.034162] [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] [Received: 02/14/2024] [Accepted: 06/18/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Elevated blood viscosity (BV), a critical determinant in blood rheology, is a contributing factor in cerebrovascular diseases. The specific influence of BV on small vessel disease burden remains unexplored. This study aims to examine the relationship between BV and regional white matter hyperintensity (WMH) volume in patients with acute ischemic stroke. METHODS AND RESULTS We enrolled a cohort of 302 patients with acute ischemic stroke or transient ischemic attack who were admitted to a hospital within 7 days of symptom onset in this study. We measured whole BV using a scanning capillary-tube viscometer and categorized systolic blood viscosity into 3 groups based on established references. We quantified and normalized WMH volumes using automated localization and segmentation software by NEUROPHET Inc. We performed multivariable logistic regression analysis to assess the correlation between systolic BV and WMH. The mean subject age was 66.7±13.4 years, and 38.7% (n=117) of the participants were female. Among a total of 302 patients, patients with higher deep WMH volume (T3) were typically older and had an atrial fibrillation, strokes of cardioembolic or undetermined cause, elevated levels of C-reactive protein, diastolic blood viscosity and systolic BV. A multivariable adjustment revealed a significant association between high systolic BV and increased deep-WMH volume (odds ratio [OR], 2.636 [95% CI, 1.225-5.673]). CONCLUSIONS Elevated systolic BV is more likely to be associated with deep WMH volume in patients with acute ischemic stroke or transient ischemic attack. These findings reveal novel therapeutic strategies focusing on blood rheology to enhance cerebral microcirculation in stroke management.
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Affiliation(s)
- Minwoo Lee
- Department of Neurology Hallym University Sacred Heart Hospital, Hallym University College of Medicine Anyang Republic of Korea
| | - Soo-Hyun Park
- Department of Neurology Soonchunhyang University Seoul Hospital Seoul Republic of Korea
| | - Yeo Jin Kim
- Department of Neurology, Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul Republic of Korea
| | - Jong Seok Bae
- Department of Neurology, Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul Republic of Korea
| | - Ju-Hun Lee
- Department of Neurology, Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul Republic of Korea
| | - Sang-Hwa Lee
- Department of Neurology Chuncheon Sacred Heart Hospital, Hallym University College of Medicine Chuncheon Republic of Korea
| | - Chulho Kim
- Department of Neurology Chuncheon Sacred Heart Hospital, Hallym University College of Medicine Chuncheon Republic of Korea
| | - Kijeong Lee
- Research Institute, NEUROPHET Inc Seoul Republic of Korea
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital Hallym University College of Medicine Seoul Republic of Korea
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Lee M, Suh CH, Sohn JH, Kim C, Han SW, Sung JH, Yu KH, Lim JS, Lee SH. Impact of white matter hyperintensity volumes estimated by automated methods using deep learning on stroke outcomes in small vessel occlusion stroke. Front Aging Neurosci 2024; 16:1399457. [PMID: 38974905 PMCID: PMC11224430 DOI: 10.3389/fnagi.2024.1399457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/31/2024] [Indexed: 07/09/2024] Open
Abstract
Introduction Although white matter hyperintensity (WMH) shares similar vascular risk and pathology with small vessel occlusion (SVO) stroke, there were few studies to evaluate the impact of the burden of WMH volume on early and delayed stroke outcomes in SVO stroke. Materials and methods Using a multicenter registry database, we enrolled SVO stroke patients between August 2013 and November 2022. The WMH volume was estimated by automated methods using deep learning (VUNO Med-DeepBrain, Seoul, South Korea), which was a commercially available segmentation model. After propensity score matching (PSM), we evaluated the impact of WMH volume on early neurological deterioration (END) and poor functional outcomes at 3-month modified Ranking Scale (mRS), defined as mRS score >2 at 3 months, after an SVO stroke. Results Among 1,718 SVO stroke cases, the prevalence of subjects with severe WMH (Fazekas score ≥ 3) was 68.9%. After PSM, END and poor functional outcomes at 3-month mRS (mRS > 2) were higher in the severe WMH group (END: 6.9 vs. 13.5%, p < 0.001; 3-month mRS > 2: 11.4 vs. 24.7%, p < 0.001). The logistic regression analysis using the PSM cohort showed that total WMH volume increased the risk of END [odd ratio [OR], 95% confidence interval [CI]; 1.01, 1.00-1.02, p = 0.048] and 3-month mRS > 2 (OR, 95% CI; 1.02, 1.01-1.03, p < 0.001). Deep WMH was associated with both END and 3-month mRS > 2, but periventricular WMH was associated with 3-month mRS > 2 only. Conclusion This study used automated methods using a deep learning segmentation model to assess the impact of WMH burden on outcomes in SVO stroke. Our findings emphasize the significance of WMH burden in SVO stroke prognosis, encouraging tailored interventions for better patient care.
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Affiliation(s)
- Minwoo Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Republic of Korea
| | - Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Republic of Korea
| | - Sang-Won Han
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Republic of Korea
| | - Joo Hye Sung
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Jae-Sung Lim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
- Institute of New Frontier Research Team, Hallym University, Chuncheon, Republic of Korea
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Chen F, Cao LH, Ma FY, Zeng LL, He JR. Development and validation of a predictive model for severe white matter hyperintensity with obesity. Front Aging Neurosci 2024; 16:1404756. [PMID: 38887608 PMCID: PMC11180876 DOI: 10.3389/fnagi.2024.1404756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Purpose The purpose of the present study was to identify predictors of severe white matter hyperintensity (WMH) with obesity (SWO), and to build a prediction model for screening obese people with severe WMH without Nuclear Magnetic Resonance Imaging (MRI) examination. Patients subjects and methods From September 2020 to October 2021, 650 patients with WMH were recruited consecutively. The subjects were divided into two groups, SWO group and non-SWO group. Univariate and Logistic regression analysis were was applied to explore the potential predictors of SWO. The Youden index method was adopted to determine the best cut-off value in the establishment of the prediction model of SWO. Each parameter had two options, low and high. The score table of the prediction model and nomogram based on the logistic regression were constructed. Of the 650 subjects, 487 subjects (75%) were randomly assigned to the training group and 163 subjects (25%) to the validation group. By resampling the area under the curve (AUC) of the subject's operating characteristics and calibration curves 1,000 times, nomogram performance was verified. A decision curve analysis (DCA) was used to evaluate the nomogram's clinical usefulness. By resampling the area under the curve (AUC) of the subject's operating characteristics and calibration curves 1,000 times, nomogram performance was verified. A decision curve analysis (DCA) was used to evaluate the nomogram's clinical usefulness. Results Logistic regression demonstrated that hypertension, uric acid (UA), complement 3 (C3) and Interleukin 8 (IL-8) were independent risk factors for SWO. Hypertension, UA, C3, IL-8, folic acid (FA), fasting C-peptide (FCP) and eosinophil could be used to predict the occurrence of SWO in the prediction models, with a good diagnostic performance, Areas Under Curves (AUC) of Total score was 0.823 (95% CI: 0.760-0.885, p < 0.001), sensitivity of 60.0%, specificity of 91.4%. In the development group, the nomogram's AUC (C statistic) was 0.829 (95% CI: 0.760-0.899), while in the validation group, it was 0.835 (95% CI: 0.696, 0.975). In both the development and validation groups, the calibration curves following 1,000 bootstraps showed a satisfactory fit between the observed and predicted probabilities. DCA showed that the nomogram had great clinical utility. Conclusion Hypertension, UA, C3, IL-8, FA, FCP and eosinophil models had the potential to predict the incidence of SWO. When the total score of the model exceeded 9 points, the risk of SWO would increase significantly, and the nomogram enabled visualization of the patient's WMH risk. The application prospect of our models mainly lied in the convenient screening of SWO without MRI examination in order to detect SWO and control the WMH hazards early.
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Affiliation(s)
- Fu Chen
- Department of Neurology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Medicine, Yinhang Community Health Centre, Shanghai, China
| | - Lin-Hao Cao
- Department of Neurology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei-Yue Ma
- Department of Neurology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-Li Zeng
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ji-Rong He
- Department of Neurology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Sohn JH, Kim C, Sung JH, Han SW, Minwoo Lee, Oh MS, Yu KH, Kim Y, Park SH, Lee SH. Effect of pre-stroke antiplatelet use on stroke outcomes in acute small vessel occlusion stroke with moderate to severe white matter burden. J Neurol Sci 2024; 456:122837. [PMID: 38141530 DOI: 10.1016/j.jns.2023.122837] [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: 10/30/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Cerebral small vessel disease is characterized by white matter hyperintensities (WMH) and acute small vessel occlusion (SVO) stroke. We investigated the effect of prior antiplatelet use (APU) on stroke outcome in 1151 patients with acute SVO stroke patients and moderate to severe WMH. METHODS Using a multicenter database, this retrospective study used quantitative WMH volume measurements and propensity score matching (PSM) for comparisons between patients with prior APU and without APU. Primary outcomes were stroke progression and poor functional outcome (modified Rankin Scale>2) at 3 months. Logistic regression analyses assessed associations between prior APU, WMH burden, and stroke outcomes. RESULTS Stroke progression was lower in the prior APU group in both the total cohort (14.8% vs. 6.9%, p < 0.001) and the PSM cohort (16.3% vs. 6.9%, p < 0.001). The proportion of poor functional outcomes at 3 months was not significantly different in the total cohort, but the PSM cohort showed a lower proportion in the prior APU group (30.8% vs. 20.2%, p = 0.002). Logistic regression analysis confirmed that prior APU was associated with a reduced risk of stroke progression (OR, 0.39; 95% CI, 0.22-0.70; p = 0.001) and poor functional outcome at 3 months (OR, 0.37; 95% CI, 0.23-0.59; p < 0.001). CONCLUSION Prior APU is associated with reduced stroke progression and improved functional outcome at 3 months in acute SVO stroke patients with moderate to severe WMH. Early treatment of WMH and acute SVO stroke may have potential benefits in improving stroke outcomes.
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Affiliation(s)
- Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea; Institute of New Frontier research Team, Hallym University, Chuncheon, South Korea
| | - Chulho Kim
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea; Institute of New Frontier research Team, Hallym University, Chuncheon, South Korea
| | - Joo Hye Sung
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sang-Won Han
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea
| | - Minwoo Lee
- Department of Neurology, Hallym Sacred Heart Hospital Hallym University College of Medicine, Anyang, South Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym Sacred Heart Hospital Hallym University College of Medicine, Anyang, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym Sacred Heart Hospital Hallym University College of Medicine, Anyang, South Korea
| | - Yerim Kim
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Soo-Hyun Park
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, South Korea; Institute of New Frontier research Team, Hallym University, Chuncheon, South Korea.
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Magnetic resonance imaging manifestations of cerebral small vessel disease: automated quantification and clinical application. Chin Med J (Engl) 2020; 134:151-160. [PMID: 33443936 PMCID: PMC7817342 DOI: 10.1097/cm9.0000000000001299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The common cerebral small vessel disease (CSVD) neuroimaging features visible on conventional structural magnetic resonance imaging include recent small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, microbleeds, and brain atrophy. The CSVD neuroimaging features have shared and distinct clinical consequences, and the automatic quantification methods for these features are increasingly used in research and clinical settings. This review article explores the recent progress in CSVD neuroimaging feature quantification and provides an overview of the clinical consequences of these CSVD features as well as the possibilities of using these features as endpoints in clinical trials. The added value of CSVD neuroimaging quantification is also discussed for researches focused on the mechanism of CSVD and the prognosis in subjects with CSVD.
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Ye S, Dong S, Tan J, Chen L, Yang H, Chen Y, Peng Z, Huo Y, Liu J, Tang M, Li Y, Zhou H, Tao Y. White-Matter Hyperintensities and Lacunar Infarcts Are Associated with an Increased Risk of Alzheimer's Disease in the Elderly in China. J Clin Neurol 2019; 15:46-53. [PMID: 30618216 PMCID: PMC6325371 DOI: 10.3988/jcn.2019.15.1.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 02/03/2023] Open
Abstract
Background and Purpose This study investigated the contribution of white-matter hyperintensities (WMH) and lacunar infarcts (LI) to the risk of Alzheimer's disease (AD) in an elderly cohort in China. Methods Older adults who were initially cognitively normal were examined with MRI at baseline, and followed for 5 years. WMH were classified as mild, moderate, or severe, and LI were classified into a few LI (1 to 3) or many LI (≥4). Cognitive function was assessed using the Mini Mental State Examination and the Activities of Daily Living scale. Results Among the 2,626 subjects, 357 developed AD by the end of the 5-year follow-up period. After adjusting for age and other potential confounders, having only WMH, having only LI, and having both WMH and LI were associated with an increased risk of developing AD compared with having neither WMH nor LI. Moderate and severe WMH were associated with an increased risk of developing AD compared with no WMH. Furthermore, patients with many LI had an increased risk of developing AD compared with no LI. Conclusions Having moderate or severe WMH and many LI were associated with an increased risk of developing AD, with this being particularly striking when both WMH and LI were present.
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Affiliation(s)
- Shuai Ye
- Battalion 3 of Cadet Brigade, Third Military Medical University (Army Medical University), Chongqing, China
| | - Shuyang Dong
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Postgraduate School, Bengbu Medical College, Anhui, China
| | - Jun Tan
- Rashid Laboratory for Developmental Neurobiology, Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Le Chen
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Postgraduate School, Bengbu Medical College, Anhui, China
| | - Hai Yang
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yang Chen
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zeyan Peng
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Postgraduate School, Bengbu Medical College, Anhui, China
| | - Yingchao Huo
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Juan Liu
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Mingshan Tang
- Department of Neurology, the People's Hospital of Banan District, Chongqing, China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University (Army Medical University), Chongqing, China
| | - Huadong Zhou
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Department of Neurology, Qianjiang National Hospital, Chongqing, China.
| | - Yong Tao
- Department of Neurology, Daping Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Xu X, Gao Y, Liu R, Qian L, Chen Y, Wang X, Xu Y. Progression of White Matter Hyperintensities Contributes to Lacunar Infarction. Aging Dis 2018; 9:444-452. [PMID: 29896432 PMCID: PMC5988599 DOI: 10.14336/ad.2017.0808] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/08/2017] [Indexed: 01/11/2023] Open
Abstract
Both white matter hyperintensities (WMHs) and lacunar infarctions (LIs) are magnetic resonance imaging (MRI) markers of cerebral small vessel disease (SVD). However, the association between WMH and LI remains unclear. In this study, we asked whether WMH progression is related to LI occurrence using retrospective data. Overall, 8475 WMH patients with at least two MRI images were screened, and 187 patients were included in the final study; 76 patients had WMH with LI (WL), and 111 patients had WMH without LI (WOL). The 187 patients were divided into three groups according to WMH progression: Group 1 (no progression), Group 2 (0-53.64% WMH progression) and Group 3 (≥53.64% WMH progression). We found that both WMH volumes and Fazekas scores were higher in WL patients compared with those in WOL patients according to the 1st and 2nd MRI images (P<0.001), whereas WMH progression was not significantly different between these two groups (P>0.05). Importantly, we found that the occurrence rates for LI were increased in Groups 2 and 3 compared with those in Group 1. Multiple logistic regression analysis demonstrated that the risk of LI occurrence was significantly increased in Group 2 versus that in Group 1 (odds ratio, 3.36; 95% CI, 1.48 to 7.67; P=0.004) after adjusting for the baseline patient characteristics and the interval between the two MRI scans. Additionally, with a stratification time of less than 24 months, the risk of LI occurrence was higher in Group 2 versus that in Group 1, after adjusting for baseline confounding factors (odds ratio, 3.68; 95% CI, 1.51 to 8.99; P=0.004). In conclusion, we found that WMH progression was significantly associated with LI occurrence, particularly within the first two years, and that this progression could serve as an independent indicator of LI development.
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Affiliation(s)
- Xin Xu
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Yuanyuan Gao
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Renyuan Liu
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Lai Qian
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Yan Chen
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
| | - Xiaoying Wang
- 4Departments of Neurology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Yun Xu
- 1Department of Neurology, Affiliated Drum Tower Hospital, and Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing 210008, China.,2Jiangsu Province Stroke Center for Diagnosis and Therapy, Nanjing 210008, China.,3Nanjing Neuropsychiatry Clinic Medical Center, Nanjing 210008, China
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