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Fullerton HJ, Hills NK, Wintermark M, Dlamini N, Amlie-Lefond C, Dowling MM, Jordan LC, Bernard TJ, Friedman NR, Elkind MSV, Grose C. Evidence of varicella zoster virus (VZV) reactivation in children with arterial ischemic stroke: Results of the VIPS II Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.26.24307958. [PMID: 38853955 PMCID: PMC11160817 DOI: 10.1101/2024.05.26.24307958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Background Varicella zoster virus (VZV) has been associated with focal cerebral arteriopathy (FCA) and arterial ischemic stroke (AIS) in childhood. The Vascular effects of Infection in Pediatric Stroke (VIPS) II study aimed to examine this relationship in the modern era when most children in North America and Australia receive VZV vaccination with live, attenuated virus. Methods This 22-center prospective cohort study enrolled 205 children (28 days-18 years) with AIS (2017-2022), collected baseline [hyperacute (≤72 hours; n=194) and acute (4-6 days; n=181)] and convalescent (1-6 weeks; n=74) serum samples. Sites enrolled 95 stroke-free controls with single serum samples. A virology research laboratory measured VZV IgM and IgG titers by an in-house enzyme-linked immunosorbent assay (ELISA). Baseline IgG seropositivity indicated prior exposure (vaccination/infection) and elevated IgM titers indicated recent reactivation. Results Median (IQR) age was 11.6 (5.5-15.6) years for cases and 11.8 (6.8-15.3) years for controls. Baseline serologies indicated prior VZV exposure in 198 cases (97%) and all controls. Parents of cases reported VZV vaccination in 160 (78%) and remote chicken pox in three (1.4%). Twenty cases (9.8%) and three controls (3.1%) had serologic evidence of recent VZV reactivation (p=0.06); all had remote VZV exposure (vaccination in 19 cases and all controls) and all were asymptomatic. Recent VZV reactivation was seen in similar proportions in arteriopathic, cardioembolic, and idiopathic stroke. Of 32 cases of FCA, 4 (12.5%) had recent VZV reactivation, versus no cases of arterial dissection (n=10) or moyamoya (n=16). Conclusions Serologic evidence of recent VZV reactivation (≈1-6 weeks prior to stroke) was present in one in 10 cases of childhood AIS, including those without arteriopathy. Clinically silent VZV reactivation may be a childhood stroke trigger despite widespread vaccination. These cases could represent waning immunity with reactivation of either vaccine virus or wild-type virus after an unrecognized secondary VZV infection.
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Kloc A, Campbell KS, Espinoza YAU. Detection of Parvovirus B19 genome in human heart tissue samples. BMC Res Notes 2023; 16:239. [PMID: 37775826 PMCID: PMC10542668 DOI: 10.1186/s13104-023-06527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVE Identifying viral genomes in human heart tissues is critical for disease diagnosis and assessment of cardiovascular damage. Human heart tissue samples obtained during a biopsy procedure are routinely used to test for the presence of viruses, as guided by clinical manifestations and prognosis. Furthermore, heart tissue samples obtained post-mortem or during a cardiac transplant procedure serve as a valuable research tool, as they allow for an in-depth assessment of cardiac pathology that can aid in our understanding of molecular pathways associated with disease. Because viral nucleic acid constitutes only a small portion of each sample's genetic material, appropriate methods are necessary for positive viral genome identification. RESULTS Snap-frozen heart tissue samples obtained either post-mortem or during a cardiac transplant procedure were used to develop conditions for detection of Parvovirus B19. Briefly, total DNA was isolated from the heart tissue under varying conditions. A PCR-based assay with Parvovirus B19 specific primers was implemented to detect the presence of the viral genome, followed by Sanger Sequencing. The mechanical disruption of the heart tissue, as well as the cardiac tissue processing methods, had a significant effect on the DNA quality and the ability to detect the Parvovirus B19 genome.
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Affiliation(s)
- Anna Kloc
- Department of Biology and Environmental Science, University of New Haven, West Haven, CT, USA.
| | - Kenneth S Campbell
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY, USA
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3
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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4
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Goetz V, Yang DD, Abid H, Roux CJ, Levy R, Kossorotoff M, Desguerre I, Angoulvant F, Aubart M. Neurological features related to influenza virus in the pediatric population: a 3-year monocentric retrospective study. Eur J Pediatr 2023:10.1007/s00431-023-04901-9. [PMID: 36947244 DOI: 10.1007/s00431-023-04901-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
Influenza virus is generally characterized by fever, myalgia, and respiratory symptoms. Neurological entities have already been described, such as acute necrotizing encephalitis (ANE). We aimed to highlight the non-exceptional nature and explore the clinical spectrum and evolution of neurological features related to influenza virus in children. This monocentric observational study included patients under 18 years old, positive for influenza virus, between January 2017 and April 2019 in a pediatric university hospital. Patients were classified into two groups: those with or without a previous significant neurological or metabolic disorder. Two hundred eighty-nine children were identified with influenza infection. Thirty seven had a neurological manifestation: 14 patients who had previous significant neurological or metabolic disorder and 23 patients with no medical history. We identified several clinical patterns: 22 patients had seizures, 7 behavior disorders, 5 disturbances of consciousness, and 3 motor deficits. Four were diagnosed with a known influenza-associated neurological syndrome: 1 ANE, 1 cytotoxic lesion of the corpus callosum, 1 hemiconvulsion-hemiplegia-epilepsia syndrome, and 1 recurrent encephalitis in the context of a RANBP2 mutation. The neurological outcome was favorable in most cases. None of the patients with previous significant disorder retained sequalae or had a recurrence. Two patients had a fatal outcome, and both had a predisposing disorder. CONCLUSION Various neurological manifestations can be associated with influenza virus. Certain entities led to a poor prognosis, but in most cases, symptoms improved within a few days. The severity of the neurological manifestations correlated with previous neurological or metabolic disorders. WHAT IS KNOWN • Influenza viruses are well known pathogens with a seasonal epidemic evolution, particularly affecting children. These viruses cause acute fever with respiratory symptoms, associated with myalgia and headaches. Neurological presentation in influenza-virus infection is a well-established possibility as influenza virus is considered to be responsible for 27 to 36% of childhood encephalitis. Some specific and severe entity as acute necrotizing encephalitis, cytotoxic lesion of the corpus callosum, or Hemiconvulsion-hemiplegia-epilepsy syndrome are well described. WHAT IS NEW • In a French monocentric cohort of 37 children with influenza-related neurologic manifestations, the majority of these manifestations, including seizure, drowsiness, motor deficiency, hallucination… are self limiting and do not lead to after-effects. In rare cases (4/37), they may reveal severe encephalitis requiring rapid and appropriate treatment. Otherwise, comparison of a group of 14 children with underlying neurological or metabolic disorder with a group of 23 children free of any significant disorder show that the severity of the neurological manifestations was largely related to previous neurological or metabolic disorders highlighting the importance of vaccination in this population.
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Affiliation(s)
- Violette Goetz
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - David-Dawei Yang
- Pediatric Emergency Department, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France
| | - Hanene Abid
- Virology Laboratory, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France
| | - Charles-Joris Roux
- Paediatric Radiology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Raphael Levy
- Paediatric Radiology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Manoelle Kossorotoff
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - Isabelle Desguerre
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France
| | - François Angoulvant
- Pediatric Emergency Department, Necker-Enfants alades Hospital, APHP, Université de Paris Citém, Paris, France.
- INSERM, Centre de Recherche des Cordeliers, UMRS 1138, Sorbonne Université, Université de Paris, Paris, France.
| | - Mélodie Aubart
- Pediatric Neurology Department, Necker-Enfants malades Hospital, APHP, Université de Paris Cité, Paris, France.
- INSERM U1163 Institut HU Imagine, Laboratory of Human Genetics of Infectious Disease, Paris, France.
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5
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Cornet MC, Grose C, Vexler Z, Wu YW, Fullerton HJ. The Role of Infection and Inflammation in the Pathogenesis of Pediatric Arterial Ischemic Stroke. Semin Pediatr Neurol 2022; 44:100995. [PMID: 36456035 DOI: 10.1016/j.spen.2022.100995] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
Infections play an important role in the pathogenesis of acute ischemic stroke (AIS) in neonates and children. In neonates, chorioamnionitis or intrauterine inflammation has been implicated as a common risk factor for AIS. In infants and children, recent investigations demonstrated that even minor childhood infections are associated with subsequent increased risk for AIS. Post-infectious inflammatory mechanisms following infections with herpesviruses may lead to focal cerebral arteriopathy (FCA), one of the most common causes of AIS in a previously healthy child. Other agents such as parvovirus B19, dengue virus, and SARS-CoV-2 have recently been implicated as other potential triggers. Infections are compelling treatable stroke risk factors, with available therapies for both pathogens and downstream inflammatory effects. However, infections are common in childhood, while stroke is uncommon. The ongoing VIPS II (Vascular effects of Infection in Pediatric Stroke) study aims to identify the array of pathogens that may lead to childhood AIS and whether either unusual strains or unusual combinations of pathogens explain this paradox. Immune modulation with corticosteroids for FCA is another active area of research, with European and U.S. trials launching soon. The results of these new pediatric stroke studies combined with findings emerging from the larger field of immune-mediated post-infectious diseases will likely lead to new approaches to the prevention and treatment of pediatric stroke. This review highlights recent developments from both clinical and animal model research enhancing our understanding of this relationship between infection, inflammation, and stroke in neonates and children.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
| | - Charles Grose
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Zinaida Vexler
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather J Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Neurology, University of California San Francisco, San Francisco, California, USA
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Liu R, Zhang Z, Chen Y, Liao J, Wang Y, Liu J, Lin Z, Xiao G. Choroid plexus epithelium and its role in neurological diseases. Front Mol Neurosci 2022; 15:949231. [PMID: 36340696 PMCID: PMC9633854 DOI: 10.3389/fnmol.2022.949231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/15/2022] [Indexed: 02/16/2024] Open
Abstract
Choroid plexus epithelial cells can secrete cerebrospinal fluid into the ventricles, serving as the major structural basis of the selective barrier between the neurological system and blood in the brain. In fact, choroid plexus epithelial cells release the majority of cerebrospinal fluid, which is connected with particular ion channels in choroid plexus epithelial cells. Choroid plexus epithelial cells also produce and secrete a number of essential growth factors and peptides that help the injured cerebrovascular system heal. The pathophysiology of major neurodegenerative disorders like Alzheimer's disease, Parkinson's disease, as well as minor brain damage diseases like hydrocephalus and stroke is still unknown. Few studies have previously connected choroid plexus epithelial cells to the etiology of these serious brain disorders. Therefore, in the hopes of discovering novel treatment options for linked conditions, this review extensively analyzes the association between choroid plexus epithelial cells and the etiology of neurological diseases such as Alzheimer's disease and hydrocephalus. Finally, we review CPE based immunotherapy, choroid plexus cauterization, choroid plexus transplantation, and gene therapy.
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Affiliation(s)
- Ruizhen Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiping Zhang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yibing Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Junbo Liao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yuchang Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jingping Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhixiong Lin
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Gelei Xiao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Diagnosis and Treatment Center for Hydrocephalus, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Chernova TM, Timchenko VN, Pavlova EB, Baracina EV, Subbotina MD. Parvovirus В19 infection: lecture. CHILDREN INFECTIONS 2022. [DOI: 10.22627/2072-8107-2022-21-3-39-46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Parvovirus B19 infection is best known as erythema infectiosum. However, infection with parvovirus B19 can lead to damage to various organs and systems, the development of severe complications up to death. The infection is most dangerous for people with immunodeficiency and hematological diseases. Serious consequences are possible with intrauterine infection of the fetus. Knowledge about the characteristics of the pathogen, the pathogenesis of the disease, the variety of clinical manifestations will allow the doctor to avoid diagnostic errors and provide the patient with timely medical care.
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8
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Kumar R, Sun LR, Rodriguez V, Sankar A, Sharma M, Meoded A, Brandão LR, Goldenberg NA. Hemostatic and Thrombotic Considerations in the Diagnosis and Management of Childhood Arterial Ischemic Stroke: A Narrative Review. Semin Pediatr Neurol 2022; 43:101003. [PMID: 36344025 DOI: 10.1016/j.spen.2022.101003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
Although rare in children, arterial ischemic stroke (AIS) is associated with increased mortality and neurological morbidity. The incidence of AIS after the neonatal period is approximately 1-2/100,000/year, with an estimated mortality of 3-7%. A significant proportion of children surviving AIS experience life-long neurological deficits including hemiparesis, epilepsy, and cognitive delays. The low incidence of childhood AIS coupled with atypical clinical-presentation and lack of awareness contribute to delay in diagnosis and consequently, the early initiation of treatment. While randomized-clinical trials have demonstrated the efficacy and safety of reperfusion therapies including thrombolysis and endovascular thrombectomy in appropriately-selected adult patients, similar data for children are unavailable. Consequently, clinical decisions surrounding reperfusion therapy in childhood AIS are either extrapolated from adult data or based on local experience. The etiology of childhood AIS is multifactorial, often occurring in the setting of both acquired and congenital risk-factors including thrombophilia. While multiple studies have investigated the association of thrombophilia with incident childhood AIS, its impact on stroke recurrence and therefore duration and intensity of antithrombotic therapy is less clear. Despite these limitations, a significant progress has been made over the last decade in the management of childhood AIS. This progress can be attributed to international consortiums, and in selected cohorts to federally-funded clinical trials. In this narrative review, the authors have systematically appraised the literature and summarize the hemostatic and thrombotic considerations in the diagnosis and management of childhood AIS focusing on the evidence supporting reperfusion therapies, relevance of thrombophilia testing, and duration and drug choices for secondary-prophylaxis.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD; Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University, Columbus, OH
| | - Mukta Sharma
- Division of Hematology, Children's Mercy Hospital, Kansas City, MO
| | - Avner Meoded
- Edward B. Singleton, Department of Radiology, Texas Children's Hospital, Houston, TX
| | - Leonardo R Brandão
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON; Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, FL; Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Nakamura Y, Mineharu Y, Kamata T, Funaki T, Miyamoto S, Koizumi A, Harada KH. Lack of Association between Seropositivity of Vasculopathy-Related Viruses and Moyamoya Disease. J Stroke Cerebrovasc Dis 2022; 31:106509. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022] Open
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10
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Elkind MSV. From the Heart to the Brain: Building Bridges to a Better Future. Stroke 2022; 53:1037-1042. [PMID: 35012329 PMCID: PMC8885844 DOI: 10.1161/strokeaha.121.036763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This Presidential Address was delivered at the International Stroke Conference in March 2021, during the coronavirus pandemic. Dr Elkind, the President of the American Heart Association (AHA) at the time, is a vascular neurologist with a research focus on stroke epidemiology. This address interweaves personal reflections on a career in clinical neurology, stroke research, and public health with a discussion of the role of the AHA in improving cardiovascular health at multiple levels. Throughout its history, the AHA has had leaders representing many different areas of cardiovascular science and medicine, including stroke. More recently, its focus has expanded from a traditional emphasis on cardiovascular events illness and events, like heart disease and stroke, to an appreciation of the role of the vascular system in brain health, healthy aging, cognitive decline, and dementia. During the pandemic, as the bidirectional effects of the coronavirus on cardiovascular disease has been elucidated, the benefits of a broad and multidisciplinary approach to cardiovascular disease and public health have become more apparent than ever. In addition, with growing awareness of the disproportionate effects of the pandemic on communities of color in the United States and globally, the AHA has redoubled its focus on addressing the social determinants of health, including structural racism. Central to these efforts is the construction of bridges between the generation of scientific knowledge and action for the public good. Our success will depend on the combination of basic, translational, clinical and population research with programs of public and professional education, advocacy, and social action.
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Affiliation(s)
- Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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11
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Gutierrez J, Katan M, Elkind MS. Inflammatory and Infectious Vasculopathies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00036-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Larson AS, Lehman VT, Savastano LE, Lanzino G, Campeau NG, Welker KM, Klaas JP. Implementation and Rationale for a Unified Clinical and Imaging Protocol for Evaluation and Treatment of Moyamoya Angiopathy: A Single Institutional Experience. Front Neurol 2021; 12:662393. [PMID: 34079514 PMCID: PMC8165224 DOI: 10.3389/fneur.2021.662393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
Moyamoya disease (MMD) is a complex and incompletely-understood cerebrovascular pathological entity that requires thorough clinical and imaging evaluation. Moyamoya is rare, thereby making the establishment of an effective, thorough and interdisciplinary patient evaluation protocol challenging, even within specialized referral centers. Nevertheless, implementation of such a protocol is crucial in order to provide the best possible evaluation and treatment for MMD patients. Here, we describe our institution's implementation of, rationale for, and experience with a comprehensive multidisciplinary collaboration and evaluation strategy for adult patients with moyamoya. This evaluation course consists of, first of all, a thorough clinical and laboratory evaluation with a vascular neurologist. This is followed by a comprehensive imaging assessment which evaluates angiographic and parenchymal features, in addition to cerebrovascular functionality. Finally, appropriate referrals are made to consulting services as indicated, which includes vascular neurosurgery. These steps are described in detail herein.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Radiology, Mayo Clinic, Rochester, MN, United States.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | | | - Kirk M Welker
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - James P Klaas
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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13
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Sarecka-Hujar B, Kopyta I. The Impact of Sex on Arterial Ischemic Stroke in Young Patients: From Stroke Occurrence to Poststroke Consequences. CHILDREN-BASEL 2021; 8:children8030238. [PMID: 33803901 PMCID: PMC8003301 DOI: 10.3390/children8030238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
Abstract
The male sex has been suggested to predominate in paediatric patients with arterial ischemic stroke (AIS), especially in newborns. The explanation for this phenomenon remains unsatisfactory since it focuses on the analysis of the potential relationship with trauma and arterial dissection. In turn, in some populations of young adults, men suffer from AIS more frequently than women, which may be related to the protective role of oestrogen. On the other hand, certain data indicate that women dominate over men. Some of the disparities in the frequencies of particular symptoms of AIS and poststroke consequences in both children and young adults have been suggested; however, data are scarce. Unfortunately, the low number of studies on the subject does not allow certain conclusions to be drawn. For adults, more data are available for patients aged over 60 years, the results of which are more obvious. The present literature review aimed to discuss available data on the prevalence of AIS, its clinical presentations, and poststroke consequences in regard to the sex of young patients. We considered young patients to be children from birth up to the age of 19 years of life and young adults to be individuals up to the age of 55 years. The role of sex hormones in AIS and possible gender differences in genetic risk factors for AIS were also discussed briefly.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence: or ; Tel.: +48-32-269-98-30
| | - Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland;
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Beslow LA, Linds AB, Fox CK, Kossorotoff M, Zuñiga Zambrano YC, Hernández-Chávez M, Hassanein SMA, Byrne S, Lim M, Maduaka N, Zafeiriou D, Dowling MM, Felling RJ, Rafay MF, Lehman LL, Noetzel MJ, Bernard TJ, Dlamini N. Pediatric Ischemic Stroke: An Infrequent Complication of SARS-CoV-2. Ann Neurol 2021; 89:657-665. [PMID: 33332607 DOI: 10.1002/ana.25991] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/14/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) include arterial ischemic stroke (AIS) in adults and multisystem inflammatory syndrome in children. Whether stroke is a frequent complication of pediatric SARS-CoV-2 is unknown. This study aimed to determine the proportion of pediatric SARS-CoV-2 cases with ischemic stroke and the proportion of incident pediatric strokes with SARS-CoV-2 in the first 3 months of the pandemic in an international cohort. METHODS We surveyed 61 international sites with pediatric stroke expertise. Survey questions included: numbers of hospitalized pediatric (≤ 18 years) patients with SARS-CoV-2; numbers of incident neonatal and childhood ischemic strokes; frequency of SARS-CoV-2 testing for pediatric patients with stroke; and numbers of stroke cases positive for SARS-CoV-2 from March 1 to May 31, 2020. RESULTS Of 42 centers with SARS-CoV-2 hospitalization numbers, 8 of 971 (0.82%) pediatric patients with SARS-CoV-2 had ischemic strokes. Proportions of stroke cases positive for SARS-CoV-2 from March to May 2020 were: 1 of 108 with neonatal AIS (0.9%), 0 of 33 with neonatal cerebral sinovenous thrombosis (CSVT; 0%), 6 of 166 with childhood AIS (3.6%), and 1 of 54 with childhood CSVT (1.9%). However, only 30.5% of neonates and 60% of children with strokes were tested for SARS-CoV-2. Therefore, these proportions represent 2.9, 0, 6.1, and 3.0% of stroke cases tested for SARS-CoV-2. Seven of 8 patients with SARS-CoV-2 had additional established stroke risk factors. INTERPRETATION As in adults, pediatric stroke is an infrequent complication of SARS-CoV-2, and SARS-CoV-2 was detected in only 4.6% of pediatric patients with ischemic stroke tested for the virus. However, < 50% of strokes were tested. To understand the role of SARS-CoV-2 in pediatric stroke better, SARS-CoV-2 testing should be considered in pediatric patients with stroke as the pandemic continues. ANN NEUROL 2021;89:657-665.
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Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexandra B Linds
- Division of Neurology, Department of Paediatrics, and Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christine K Fox
- Departments of Neurology and Pediatrics, University of California San Francisco, San Francisco, CA
| | - Manoëlle Kossorotoff
- French Center for Pediatric Stroke, Pediatric Neurology Department, APHP University Hospital Necker-Enfants Maladies, Paris, France
| | | | - Marta Hernández-Chávez
- Unit of Neurology, Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sahar M A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Susan Byrne
- Evelina London Children's Hospital, London, UK.,FutureNeuro, Royal College of Surgeons, Dublin, Ireland
| | - Ming Lim
- Evelina London Children's Hospital, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nkechi Maduaka
- Paediatric Department, King's College Hospital, London, UK
| | - Dimitrios Zafeiriou
- Department of Pediatrics, Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | - Michael M Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mubeen F Rafay
- Section of Neurology, Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Michael J Noetzel
- Departments of Neurology and Pediatrics, Division of Pediatric and Developmental Neurology, Washington University School of Medicine, Neurorehabilitation Program, St. Louis Children's Hospital, St. Louis, MO
| | - Timothy J Bernard
- Section of Child Neurology, Children's Hospital Colorado, Departments of Pediatrics and Neurology, Hemophilia and Thrombosis Center, University of Colorado School of Medicine, Aurora, CO
| | - Nomazulu Dlamini
- Division of Neurology, Department of Paediatrics, and Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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15
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Elkind MSV, Boehme AK, Smith CJ, Meisel A, Buckwalter MS. Infection as a Stroke Risk Factor and Determinant of Outcome After Stroke. Stroke 2020; 51:3156-3168. [PMID: 32897811 DOI: 10.1161/strokeaha.120.030429] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Understanding the relationship between infection and stroke has taken on new urgency in the era of the coronavirus disease 2019 (COVID-19) pandemic. This association is not a new concept, as several infections have long been recognized to contribute to stroke risk. The association of infection and stroke is also bidirectional. Although infection can lead to stroke, stroke also induces immune suppression which increases risk of infection. Apart from their short-term effects, emerging evidence suggests that poststroke immune changes may also adversely affect long-term cognitive outcomes in patients with stroke, increasing the risk of poststroke neurodegeneration and dementia. Infections at the time of stroke may also increase immune dysregulation after the stroke, further exacerbating the risk of cognitive decline. This review will cover the role of acute infections, including respiratory infections such as COVID-19, as a trigger for stroke; the role of infectious burden, or the cumulative number of infections throughout life, as a contributor to long-term risk of atherosclerotic disease and stroke; immune dysregulation after stroke and its effect on the risk of stroke-associated infection; and the impact of infection at the time of a stroke on the immune reaction to brain injury and subsequent long-term cognitive and functional outcomes. Finally, we will present a model to conceptualize the many relationships among chronic and acute infections and their short- and long-term neurological consequences. This model will suggest several directions for future research.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Amelia K Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom (C.J.S.)
| | - Andreas Meisel
- Center for Stroke Research Berlin, Department for Experimental Neurology, Department of Neurology, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Germany (A.M.)
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, CA (M.S.B.)
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16
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Echizenya I, Tokairin K, Kawabori M, Kazumata K, Houkin K. Reversible Cerebral Angiopathy after Viral Infection in a Pediatric Patient with Genetic Variant of RNF213. J Stroke Cerebrovasc Dis 2019; 29:104549. [PMID: 31818681 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/29/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022] Open
Abstract
Ring finger protein (RNF) 213 is known as a susceptibility gene for moyamoya disease (MMD), which is characterized by bilateral carotid folk stenosis. Cerebral angiopathy after viral infection has been known to present angiographical appearance resembling MMD, however its pathogenesis and genetic background are not well known. We report a case of reversible cerebral angiopathy after viral infection in a pediatric patient with genetic variant of RNF213 mutation. The patient had developed a severe headache after hand, foot, and mouth disease. Magnetic resonance imaging and magnetic resonance angiography (MRA) performed 2-3 weeks after disease onset revealed bilateral carotid folk stenosis and an old cerebral infarction in the left putamen. The patient's headache spontaneously resolved and the follow-up MRA showed a complete spontaneous resolution of the arterial stenosis after 9 months. We were able to determine genetic predisposition to angiopathy by identifying the RNF213 c.14576G>A (rs112735431, p.R4859K) mutation. Based on the present case, we hypothesize that an RNF213 variant might play an important role for the onset of postviral cerebral angiopathy.
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Affiliation(s)
- Ikuma Echizenya
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Masahito Kawabori
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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17
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Gerstl L, Weinberger R, Heinen F, Bonfert MV, Borggraefe I, Schroeder AS, Tacke M, Landgraf MN, Vill K, Kurnik K, Sorg AL, Olivieri M. Arterial ischemic stroke in infants, children, and adolescents: results of a Germany-wide surveillance study 2015–2017. J Neurol 2019; 266:2929-2941. [DOI: 10.1007/s00415-019-09508-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
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18
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Forbes HJ, Williamson E, Benjamin L, Breuer J, Brown MM, Langan SM, Minassian C, Smeeth L, Thomas SL, Warren-Gash C. Association of herpesviruses and stroke: Systematic review and meta-analysis. PLoS One 2018; 13:e0206163. [PMID: 30462656 PMCID: PMC6248930 DOI: 10.1371/journal.pone.0206163] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Herpesviruses induce a range of inflammatory effects potentially contributing to an increased risk of stroke. OBJECTIVES To investigate whether patients with infection, or reactivation of, human herpesviruses are at increased stroke risk, compared to those without human herpesviruses. DATA SOURCES Six medical databases and grey literature sources from inception to January 2017. STUDY ELIGIBILITY CRITERIA Studies where the exposure was any human herpesvirus and the outcome was stroke. We included randomised controlled trials, cohort, case-control, case-crossover and self-controlled case series designs. METHODS Meta-analyses when sufficiently homogeneous studies were available. Quality of evidence across studies was assessed. RESULTS We identified 5012 publications; 41 met the eligibility criteria. Across cohort and self-controlled case series studies, there was moderate quality evidence that varicella infection in children was associated with a short-term increased stroke risk. Zoster was associated with a 1.5-fold increased stroke risk four weeks following onset (summary estimate: 1.55, 95%CI 1.46-1.65), which resolved after one year. Subgroup analyses suggested post-zoster stroke risk was greater among ophthalmic zoster patients, younger individuals and those not prescribed antivirals. Recent infection/reactivation of cytomegalovirus and herpes simplex viruses, but not past infection, was associated with increased stroke risk; however the evidence across studies was mainly derived from small, very low quality case-control studies. CONCLUSIONS Our review shows an increased stroke risk following zoster and suggests that recent infection or reactivation of other herpesviruses increases stroke risk, although better evidence is needed. Herpesviruses are common and potentially preventable; these findings may have implications for reducing stroke burden.
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Affiliation(s)
- Harriet J. Forbes
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | | | - Laura Benjamin
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, UCL, London, United Kingdom
| | - Judith Breuer
- UCL Division of Infection & Immunity, UCL, London, United Kingdom
| | - Martin M. Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, UCL, London, United Kingdom
| | - Sinéad M. Langan
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Caroline Minassian
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Liam Smeeth
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
| | - Sara L. Thomas
- Faculty of Epidemiology & Population Health, LSHTM, London, United Kingdom
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19
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Medina MT, Medina-Montoya M. New spectrum of the neurologic consequences of Zika. J Neurol Sci 2017; 383:214-215. [DOI: 10.1016/j.jns.2017.10.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/26/2017] [Indexed: 02/02/2023]
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