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Kaufmann JE, Gensicke H, Schaedelin S, Luft AR, Goeggel-Simonetti B, Fischer U, Michel P, Strambo D, Kägi G, Vehoff J, Nedeltchev K, Kahles T, Kellert L, Rosenbaum S, von Rennenberg R, Riegler C, Seiffge D, Sarikaya H, Zietz A, Wischmann J, Polymeris AA, Hänsel M, Globas C, Bonati LH, Brehm A, De Marchis GM, Peters N, Nolte CH, Christensen H, Wegener S, Psychogios MN, Arnold M, Lyrer P, Traenka C, Engelter ST. Toward Individual Treatment in Cervical Artery Dissection: Subgroup Analysis of the TREAT-CAD Randomized Trial. Ann Neurol 2024; 95:886-897. [PMID: 38362818 DOI: 10.1002/ana.26886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Uncertainty remains regarding antithrombotic treatment in cervical artery dissection. This analysis aimed to explore whether certain patient profiles influence the effects of different types of antithrombotic treatment. METHODS This was a post hoc exploratory analysis based on the per-protocol dataset from TREAT-CAD (NCT02046460), a randomized controlled trial comparing aspirin to anticoagulation in patients with cervical artery dissection. We explored the potential effects of distinct patient profiles on outcomes in participants treated with either aspirin or anticoagulation. Profiles included (1) presenting with ischemia (no/yes), (2) occlusion of the dissected artery (no/yes), (3) early versus delayed treatment start (>median), and (4) intracranial extension of the dissection (no/yes). Outcomes included clinical (stroke, major hemorrhage, death) and magnetic resonance imaging outcomes (new ischemic or hemorrhagic brain lesions) and were assessed for each subgroup in separate logistic models without adjustment for multiple testing. RESULTS All 173 (100%) per-protocol participants were eligible for the analyses. Participants without occlusion had decreased odds of events when treated with anticoagulation (odds ratio [OR] = 0.28, 95% confidence interval [CI] = 0.07-0.86). This effect was more pronounced in participants presenting with cerebral ischemia (n = 118; OR = 0.16, 95% CI = 0.04-0.55). In the latter, those with early treatment (OR = 0.26, 95% CI = 0.07-0.85) or without intracranial extension of the dissection (OR = 0.34, 95% CI = 0.11-0.97) had decreased odds of events when treated with anticoagulation. INTERPRETATION Anticoagulation might be preferable in patients with cervical artery dissection presenting with ischemia and no occlusion or no intracranial extension of the dissection. These findings need confirmation. ANN NEUROL 2024;95:886-897.
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Affiliation(s)
- Josefin E Kaufmann
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Sabine Schaedelin
- Department of Clinical Research, Clinical Trial Unit, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas R Luft
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
- Center for Neurology and Rehabilitation, Cereneo, Vitznau, Switzerland
| | - Barbara Goeggel-Simonetti
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neuropediatrics, Institute of Pediatrics of Southern Switzerland, San Giovanni Hospital, Bellinzona, Switzerland
| | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center and Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Georg Kägi
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Jochen Vehoff
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology and Stroke Center, Cantonal Hospital Aarau, Aarau, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Regina von Rennenberg
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - David Seiffge
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | | | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Hänsel
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Christoph Globas
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology and Stroke Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Healths at Charité, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Susanne Wegener
- Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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Li H, Xu S, Xu B, Zhang Y, Yin J, Yang Y. Unraveling the Links between Chronic Inflammation, Autoimmunity, and Spontaneous Cervicocranial Arterial Dissection. J Clin Med 2023; 12:5132. [PMID: 37568534 PMCID: PMC10419694 DOI: 10.3390/jcm12155132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/12/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
Advances in imaging techniques have led to a rise in the diagnosis of spontaneous cervicocranial arterial dissection (SCCAD), which is now considered a common cause of stroke in young adults. However, our understanding of the pathophysiological mechanisms underlying SCCAD remains limited. Prior studies have proposed various factors contributing to arterial wall weakness or stress as potential causes for SCCAD. A combination of biopsies, case reports, and case-control studies suggests that inflammatory changes and autoimmunity may play roles in the cascade of events leading to SCCAD. In this review, we examine the close relationship between SCCAD, chronic inflammation, and autoimmune diseases, aiming to explore potential underlying pathophysiological mechanisms connecting these conditions. While some relevant hypotheses and studies exist, direct evidence on this topic is still relatively scarce. Further investigation of the underlying mechanisms in larger clinical cohorts is needed, and the exploration of animal models may provide novel insights.
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Affiliation(s)
- Hao Li
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China; (H.L.); (B.X.)
| | - Shiyao Xu
- The Institute of Neuroscience, Soochow University, Suzhou 215006, China; (S.X.); (Y.Z.)
| | - Beibei Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China; (H.L.); (B.X.)
| | - Yutong Zhang
- The Institute of Neuroscience, Soochow University, Suzhou 215006, China; (S.X.); (Y.Z.)
| | - Jun Yin
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Yi Yang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou 215006, China; (H.L.); (B.X.)
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Zhang S, Huang S, Hu D, Jiang F, Lv Y, Liu G. Biological Properties and Clinical Significance of Lipoprotein-Associated Phospholipase A 2 in Ischemic Stroke. Cardiovasc Ther 2022; 2022:3328574. [PMID: 36313479 PMCID: PMC9586817 DOI: 10.1155/2022/3328574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/29/2022] [Indexed: 11/27/2022] Open
Abstract
Ischemic stroke, which occurs following blockage of the blood supply to the brain, is a leading cause of death worldwide. Its main cause is atherosclerosis, a disease of the arteries characterized by the deposition of plaques of fatty material on the inner artery walls. Multiple proteins involved in the inflammation response have been identified as diagnosing biomarkers of ischemic stroke. One of these is lipoprotein-associated phospholipase A2 (Lp-PLA2), an enzyme that can hydrolyze circulating oxidized phospholipids, generating proinflammatory lysophosphatidylcholine and promoting the development of atherosclerosis. In the last two decades, a number of studies have revealed that both the concentration and the activity of Lp-PLA2 are independent biomarkers of ischemic stroke. The US Food and Drug Administration (FDA) has approved two tests to determine Lp-PLA2 mass and activity for predicting stroke. In this review, we summarize the biological properties of Lp-PLA2, the detection sensitivity and limitations of Lp-PLA2 measurement, the clinical significance and association of Lp-PLA2 in ischemic stroke, and the prospects of therapeutic inhibition of Lp-PLA2 as an intervention and treatment.
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Affiliation(s)
- Shuang Zhang
- Department of Laboratory, Hospital 3201, Hanzhong, 723000 Shaanxi, China
| | - Shuchun Huang
- Department of Neurology, Hospital 302 Attached to Guizhou Aviation Group, Anshun, 561000 Guizhou, China
| | - Dingju Hu
- Department of Neurology, Hospital 302 Attached to Guizhou Aviation Group, Anshun, 561000 Guizhou, China
| | | | - Yanli Lv
- Biotecnovo (Beijing) Co. Ltd., Beijing 100176, China
| | - Guoqi Liu
- Biotecnovo (Beijing) Co. Ltd., Beijing 100176, China
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Primary stent implantation for bilateral spontaneous cervical ICA dissections with hypoperfusion after 72 h from onset: a case report. CVIR Endovasc 2022; 5:40. [PMID: 35962854 PMCID: PMC9375808 DOI: 10.1186/s42155-022-00318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Spontaneous cervical internal carotid artery dissection (cICAD) is a common cause of stroke in young adults. Endovascular therapy is an indispensable treatment for cICAD in some cases, but it faces great challenges. Case presentation A bilateral spontaneous cICADs with hypoperfusion-related AIS after 72 h from the onset was presented herein. The patient responded well to primary Solitaire stent detachment at the critical flow-limiting site. Conclusions Primary stent implantation at the critical flow-limiting site rather than covering the entire dissection may be a therapeutic option in spontaneous cICAD complicated with cerebral hypoperfusion. The Solitaire stent may be a good choice at the acute and subacute stages of cICAD.
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Pezzini D, Grassi M, Zedde ML, Zini A, Bersano A, Gandolfo C, Silvestrelli G, Baracchini C, Cerrato P, Lodigiani C, Marcheselli S, Paciaroni M, Rasura M, Cappellari M, Del Sette M, Cavallini A, Morotti A, Micieli G, Lotti EM, Delodovici ML, Gentile M, Magoni M, Azzini C, Calloni MV, Giorli E, Braga M, La Spina P, Melis F, Tassi R, Terruso V, Calabrò RS, Piras V, Giossi A, Locatelli M, Mazzoleni V, Sanguigni S, Zanferrari C, Mannino M, Colombo I, Dallocchio C, Nencini P, Bignamini V, Adami A, Costa P, Bella R, Pascarella R, Padovan A, Pezzini A. Antithrombotic therapy in the postacute phase of cervical artery dissection: the Italian Project on Stroke in Young Adults Cervical Artery Dissection. J Neurol Neurosurg Psychiatry 2022; 93:686-692. [PMID: 35508372 DOI: 10.1136/jnnp-2021-328338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the impact of antithrombotic therapy discontinuation in the postacute phase of cervical artery dissection (CeAD) on the mid-term outcome of these patients. METHODS In a cohort of consecutive patients with first-ever CeAD, enrolled in the setting of the multicentre Italian Project on Stroke in Young Adults Cervical Artery Dissection, we compared postacute (beyond 6 months since the index CeAD) outcomes between patients who discontinued antithrombotic therapy and patients who continued taking antithrombotic agents during follow-up. Primary outcome was a composite of ischaemic stroke and transient ischaemic attack. Secondary outcomes were (1) Brain ischaemia ipsilateral to the dissected vessel and (2) Recurrent CeAD. Associations with the outcome of interest were assessed by the propensity score (PS) method. RESULTS Of the 1390 patients whose data were available for the outcome analysis (median follow-up time in patients who did not experience outcome events, 36.0 months (25th-75th percentile, 62.0)), 201 (14.4%) discontinued antithrombotic treatment. Primary outcome occurred in 48 patients in the postacute phase of CeAD. In PS-matched samples (201 vs 201), the incidence of primary outcomes among patients taking antithrombotics was comparable with that among patients who discontinued antithrombotics during follow-up (5.0% vs 4.5%; p(log rank test)=0.526), and so was the incidence of the secondary outcomes ipsilateral brain ischaemia (4.5% vs 2.5%; p(log rank test)=0.132) and recurrent CeAD (1.0% vs 1.5%; p(log rank test)=0.798). CONCLUSIONS Discontinuation of antithrombotic therapy in the postacute phase of CeAD does not appear to increase the risk of brain ischaemia during follow-up.
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Affiliation(s)
- Debora Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Mario Grassi
- Dipartimento di Scienze del Sistema Nervoso e del Comportamento, Unità di Statistica Medica e Genomica, Università di Pavia, Pavia, Italia
| | - Maria Luisa Zedde
- S.C Neurologia, Stroke Unit, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Andrea Zini
- UOC Neurologia e Rete Stroke metropolitana, IRCCS Istituto di Scienze Neurologiche di Bologna, Ospedale Maggiore, Bologna, Italia
| | - Anna Bersano
- U.O Malattie Cerebrovascolari, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milano, Italia
| | - Carlo Gandolfo
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili, Università di Genova, Genova, Italia
| | - Giorgio Silvestrelli
- Stroke Unit, Dipartimento di Neuroscienze, Ospedale "Carlo Poma", Mantova, Italia
| | - Claudio Baracchini
- UOSD Stroke Unit e Laboratorio di Neurosonologia, Azienda Ospedale-Università Padova, Padova, Italia
| | - Paolo Cerrato
- Stroke Unit, Dipartimento di Neuroscienze, Ospedale Molinette, Università di Torino, Torino, Italia
| | | | - Simona Marcheselli
- Neurologia d'urgenza e Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Italia
| | - Maurizio Paciaroni
- Internal, Vascular and Emergency Medicine - Stroke Unit, Università degli Studi di Perugia - Azienda Ospedaliera Santa Maria della Misericordia, Perugia, Italia
| | - Maurizia Rasura
- Stroke Unit, Azienda Ospedaliera "Sant'Andrea", Università "La Sapienza", Roma, Italia
| | - Manuel Cappellari
- Sroke Unit, Azienda Ospedaliera Universitaria Integrata Borgo Trento, Verona, Italia
| | - Massimo Del Sette
- U,O Neurologia, IRCCS Ospedale Policlinico "San Martino", Genova, Italia
| | - Anna Cavallini
- U.O Malattie Cerebrovascolari e Stroke Unit, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italia
| | - Andrea Morotti
- Dipartimento di Scienze Neurologiche e della Visione, ASST Spedali Civili, Brescia, Italia
| | - Giuseppe Micieli
- Neurologia d'Urgenza, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italia
| | | | | | - Mauro Gentile
- UOC Neurologia e Rete Stroke metropolitana, IRCCS Istituto di Scienze Neurologiche di Bologna, Ospedale Maggiore, Bologna, Italia
| | - Mauro Magoni
- Dipartimento di Scienze Neurologiche e della Visione, Neurologia Vascolare, ASST Spedali Civili di Brescia, Brescia, Italia
| | - Cristiano Azzini
- U.O. Neurologia, Stroke Unit, Azienda Ospedaliera "S. Anna", Università di Ferrara, Ferrara, Italia
| | | | - Elisa Giorli
- U.O Neurologia, Ospedale "Sant'Andrea", La Spezia, Italia
| | | | - Paolo La Spina
- U.O.S.D Stroke Unit, Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italia
| | - Fabio Melis
- S.S Neurovascolare, ASL Città di Torino, Ospedale "Maria Vittoria", Torino, Italia
| | - Rossana Tassi
- U.O.C Stroke Unit, Dipartimento di Scienze Mediche, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italia
| | | | | | - Valeria Piras
- S.C Neurologia e Stroke Unit, Dipartimento di Neuroscienze e Riabilitazione, Azienda Ospedaliera "G. Brotzu", Cagliari, Italia
| | - Alessia Giossi
- U.O Neurologia, Istituti Ospedalieri, ASST Cremona, Cremona, Italia
| | - Martina Locatelli
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Valentina Mazzoleni
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Sandro Sanguigni
- Dipartimento di Neurologia, Ospedale "Madonna del Soccorso", San Benedetto del Tronto, Italia
| | - Carla Zanferrari
- U.O.C Neurologia - Stroke Unit, ASST Melegnano-Martesana, Vizzolo Predabissi, Italia
| | | | - Irene Colombo
- S.C Neurologia e Unità Neurovascolare, Ospedale di Desio, ASST Brianza, Desio, Italia
| | - Carlo Dallocchio
- Dipartimento di Area Medica, U.O.C Neurologia, Ospedale Civile di Voghera, ASST Pavia, Voghera, Italia
| | - Patrizia Nencini
- Stroke Unit, Università degli Studi di Firenze, Azienda Ospedaliero-Universitaria di Careggi, Firenze, Italia
| | - Valeria Bignamini
- U.O Neurologia, Stroke Unit, Ospedale "S. Chiara", APSS Trento, Trento, Italia
| | - Alessandro Adami
- Dipartimento di Neurologia, Stroke Center, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar, Italia
| | - Paolo Costa
- U.O Neurologia, Istituto Ospedaliero Poliambulanza, Brescia, Italia
| | - Rita Bella
- Dipartimento di Scienze Mediche e Chirurgiche e Tecnologie Avanzate, Sezione di Neuroscienze, Università di Catania, Catania, Italia
| | - Rosario Pascarella
- S.S.D Neuroradiologia, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italia
| | - Alessandro Padovan
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
| | - Alessandro Pezzini
- Dipartimento di Scienze Cliniche e Sperimentali, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italia
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