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Yan J, Li Z, Wills M, Rajah G, Wang X, Bai Y, Dong P, Zhao X. Intracranial microembolic signals might be a potential risk factor for cognitive impairment. Neurol Res 2021; 43:867-873. [PMID: 34409926 DOI: 10.1080/01616412.2021.1939488] [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: 10/20/2022]
Abstract
Objective: We aimed to explore the relationship between microembolic signals (MES) and cognitive impairment in patients with neurological disorders using a 30-minute MES monitoring test.Methods: We retrospectively reviewed patients who visited outpatient departments and underwent a 30-minute MES monitoring session using dual-channel transcranial doppler (TCD) at Beijing Tiantan hospital between July 2016 and December 2018. All patients completed the Montreal Cognitive Assessment (MoCA) and underwent magnetic resonance imaging (MRI). Cognitive impairment was defined as a MoCA score of less than 26. MES were identified according to the criteria of the International Consensus Group on Microembolus Detection.Results: Of the 1356 subjects who underwent MES monitoring, 159 patients (including 50 cases of MES positive and 109 cases of MES negative) had both analyzable MES monitoring recording and cognition evaluation data, of which 72 had cognitive impairment. Compared with the group with no deficits in cognitive function, the proportion of MES positive was significantly higher in patients with impaired cognitive function - that is, 47% (34/72) versus 18.4% (16/87), respectively, with p < 0.05. In multivariate logistic regression analysis, MES were independently associated with lower MoCA score (odd ratios (OR), 7.36; 95% confidence intervals (CI), 2.72-19.85, P < 0.0001).Conclusions: In this retrospective study, we found a possible correlation and relationship between MES and cognitive impairment. Further studies are required to determine whether continuous cerebral microembolization to the brain will lead to progressive cognitive impairment.
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Affiliation(s)
- Jing Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zhaoxia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Melissa Wills
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Gary Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, USA
| | - Xin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yaqiu Bai
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pei Dong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of neurology, China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of neurology, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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2
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Donnellan C, Cohen H, Werring DJ. Cognitive dysfunction and associated neuroimaging biomarkers in antiphospholipid syndrome: a systematic review. Rheumatology (Oxford) 2021; 61:24-41. [PMID: 34003972 PMCID: PMC8742819 DOI: 10.1093/rheumatology/keab452] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives Cognitive dysfunction is common in patients with aPL (including primary APS or APS associated with SLE). Neuroimaging biomarkers may contribute to our understanding of mechanisms of cognitive dysfunction in these cohorts. This review aimed to investigate: (i) the prevalence of cognitive dysfunction in studies including neuroimaging biomarkers; and (ii) associations between cognition and neuroimaging biomarkers in patients with APS/aPL. Methods We conducted a systematic search of electronic databases PubMed, Science Direct, Scopus and PsycINFO, and included studies with descriptions of neuroimaging findings, cognitive dysfunction or both, in patients with aPL positivity (LA, IgG and IgM aCL and anti-β2 glycoprotein-I antibodies). Results Of 120 search results we included 20 eligible studies (6 APS, 4 SLE with APS/aPL and 10 NPSLE). We identified a medium risk of bias in 6/11 (54%) of cohort studies and 44% of case–control studies, as well as marked heterogeneity in cognitive assessment batteries, APS and aPL definitions, and neuroimaging modalities and protocols. The prevalence of cognitive dysfunction ranged between 11 and 60.5%. Structural MRI was the most common imaging modality, reporting cognitive dysfunction to be associated with white matter hyperintensities, ischaemic lesions and cortical atrophy (four with cerebral atrophy, two with white matter hyperintensities and two with cerebral infarcts). Conclusion Our findings confirm that cognitive impairment is commonly found in patients with aPL (including APS, SLE and NPSLE). The risk of bias, and heterogeneity in the cognitive and neuroimaging biomarkers reported does not allow for definitive conclusions.
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Affiliation(s)
- Claire Donnellan
- School of Nursing and Midwifery, Faculty of Health Sciences, University of Dublin, Trinity College Dublin, Dublin, Ireland
- Correspondence to: Claire Donnellan, School of Nursing and Midwifery, Faculty of Health Sciences, University of Dublin Trinity College, 2 Clare Street, Dublin 2, Ireland. E-mail:
| | - Hannah Cohen
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
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3
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Ricarte IF, Dutra LA, Barsottini OGP, Souza AWSD, Andrade DCOD, Mangueira C, Silva GS. Transcranial Doppler findings in antiphospholipid syndrome. Lupus 2019; 28:483-491. [PMID: 30755144 DOI: 10.1177/0961203319828833] [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] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Transcranial Doppler is a method that enables the assessment of different cerebral hemodynamic parameters. It also allows for the evaluation of the presence of right-to-left circulation shunts (RLS) and for the detection of microembolic signals (MESs), which might be associated with an increased risk of cerebrovascular events. For instance, the presence of MESs on transcranial Doppler in patients with systemic lupus erythematous (SLE) and antiphospholipid syndrome (APS) is associated with an increased risk of stroke. Therefore, transcranial Doppler could be a useful tool for stroke risk stratification in these patients. OBJECTIVE Our objective was to evaluate transcranial Doppler cerebral mean blood flow velocities as well as the presence of MESs and RLS in patients with antiphospholipid syndrome and SLE. PATIENTS AND METHODS Twenty-two patients with primary APS (PAPS), 24 patients with secondary APS (SAPS), 27 patients with SLE without APS and 21 healthy controls were evaluated. Clinical and epidemiological data were compiled from medical charts, and all subjects underwent transcranial Doppler examination with breath-holding index calculation. Both middle cerebral arteries were monitored for 60 min for the detection of MESs. RLS was investigated with agitated saline injected as a bolus. RESULTS There were no significant differences in mean blood flow velocities among the groups. MESs were more frequently found in patients with SLE when compared with controls and patients with APS (SLE: 17.4%, SAPS: 4.3%, PAPS: 0%, controls: 0%, p = 0.03). Anticoagulant therapy was more frequently used in the APS group (PAPS: 81.8%, SAPS: 75.2%, SLE: 1.7%, p < 0.001). Patients with APS had a higher frequency of RLS when compared with volunteers (63.6% versus 38.1%, p = 0.05). Breath-holding index values tended to be lower in patients with SAPS than in control subjects and patients with PAPS and SLE ( p = 0.06). CONCLUSIONS Patients with APS had a higher frequency of RLS than healthy controls. This finding alerts to the importance of cardiac investigation in patients with stroke and APS, because further therapies such as RLS occlusion might eventually add protection. The higher frequency of MES in patients with SLE could suggest an effect of anticoagulant therapy on MES prevention, more frequently used in patients with APS.
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Affiliation(s)
- I F Ricarte
- 1 Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - L A Dutra
- 1 Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,2 Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - O G P Barsottini
- 1 Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - A W S de Souza
- 3 Rheumatology Division, Department of Internal Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - D C O de Andrade
- 4 Rheumatology Division, Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Clp Mangueira
- 5 Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G S Silva
- 1 Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,5 Hospital Israelita Albert Einstein, São Paulo, Brazil
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Kargiotis O, Psychogios K, Safouris A, Magoufis G, Zervas PD, Stamboulis E, Tsivgoulis G. The Role of Transcranial Doppler Monitoring in Patients with Multi‐Territory Acute Embolic Strokes: A Review. J Neuroimaging 2019; 29:309-322. [DOI: 10.1111/jon.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
| | | | - Apostolos Safouris
- Stroke UnitMetropolitan Hospital Piraeus Greece
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Paschalis D. Zervas
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
| | | | - Georgios Tsivgoulis
- Second Department of NeurologyNational & Kapodistiran University of Athens, School of Medicine, “Attikon” University Hospital Athens Greece
- Department of NeurologyThe University of Tennessee Health Science Center Memphis TN
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5
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Zardi EM, Giorgi C, Zardi DM. Diagnostic approach to neuropsychiatric lupus erythematosus: what should we do? Postgrad Med 2018; 130:536-547. [PMID: 29940795 DOI: 10.1080/00325481.2018.1492309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Neuropsychiatric systemic lupus erythematosus is a diagnostic challenge due to the multifarious neurological and psychiatric manifestations that define it but, when suspected, diagnostic imaging can give a fundamental help. The advancements and variety of neuroimaging techniques allow us to perform more and more accurate evaluations of structure, perfusion, and metabolism of the brain and to detect cerebral and spinal lesions. Moreover, vascular districts of the neck and the brain, as well as the electrical brain and peripheral muscle activity may be accurately investigated, thus giving us a wide panoramic view. Although magnetic resonance is recognized as a fundamental neuroimaging technique to reach a correct diagnosis, the juxtaposition of other diagnostic techniques has improved the possibility to make diagnoses but has also increased the confusion about deciding which of them to use and when. Our aim was to combine the number of available techniques with the need to simplify the diagnostic path. Therefore, through the construction of an algorithm from an evidence based approach, we believe we are providing some added improvements to facilitate and expedite the diagnosis of NPSLE.
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Affiliation(s)
| | - Chiara Giorgi
- b Radiology Department , S Maria della Misericordia Hospital , Urbino , Italy
| | - Domenico Maria Zardi
- c Division of Cardiology, Faculty of Medicine and Psychology , University of Rome "Sapienza", Sant'Andrea Hospital , Rome , Italy
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Bortoluzzi A, Padovan M, Azzini C, De Vito A, Trotta F, Govoni M. Brain unidentified bright objects (“UBO”) in systemic lupus erythematosus: sometimes they come back. A study of microembolism by cMRI and Transcranial Doppler ultrasound. Lupus 2015; 25:193-8. [DOI: 10.1177/0961203315608256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/26/2015] [Indexed: 11/16/2022]
Abstract
Objectives The objectives of this report are to assess the occurrence of microembolic signals (MES) detected by transcranial Doppler ultrasound (TCD) in systemic lupus erythematosus (SLE) patients with (NPSLE) and without (SLE) neuropsychiatric involvement, and to verify the correlation between MES, clinical characteristics, especially the patent foramen ovale (PFO), and the presence of punctuate T2-hyperintense white matter lesions (WMHLs) detected by conventional magnetic resonance imaging (cMRI). Methods A TCD registration to detect MES from the middle cerebral artery was carried out in SLE and NPSLE patients after exclusion of aortic and/or carotid atheromatous disease. In all patients conventional brain magnetic resonance imaging (cMRI) and transesophageal echocardiography were performed. Patients were stratified in two groups, with and without WMHLs, and compared. Results Twenty-three SLE patients (16 NPSLE and seven SLE) were enrolled in the study. Overall MES were detected in 12 patients (52.1%), WHMLs were detectable in 15 patients (13 NPSLE and two SLE) while eight patients had normal cMRI (three NPSLE and five SLE). Matching TCD ultrasound and neuroimaging data, MES were detected in 10 (nine NPSLE and one SLE) out of 15 patients with WHMLs and in only two out of eight patients (two NPSLE and six SLE) with normal cMRI, both with NP involvement. A PFO was confirmed in all cases of MES detection. Conclusion MES are frequent findings in SLE patients, especially in those with focal WMHLs detected by cMRI and correlating with PFO. These findings should be taken into account and suggest caution in the interpretation of cMRI pictures along with a careful evaluation of MES in patients with cMRI abnormalities that should be included in the workup of SLE patients.
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Affiliation(s)
- A Bortoluzzi
- Department of Medical Science, Section of Rheumatology, University of Ferrara and Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
| | - M Padovan
- Department of Medical Science, Section of Rheumatology, University of Ferrara and Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
| | - C Azzini
- Department of Neuroscience, Section of Neurology, Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
| | - A De Vito
- Department of Neuroscience, Section of Neurology, Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
| | - F Trotta
- Department of Medical Science, Section of Rheumatology, University of Ferrara and Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
| | - M Govoni
- Department of Medical Science, Section of Rheumatology, University of Ferrara and Azienda Ospedaliero Universitaria Sant’Anna di Cona, Ferrara, Italy
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Zardi EM, Taccone A, Marigliano B, Margiotta DP, Afeltra A. Neuropsychiatric systemic lupus erythematosus: Tools for the diagnosis. Autoimmun Rev 2014; 13:831-9. [DOI: 10.1016/j.autrev.2014.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/30/2014] [Indexed: 01/18/2023]
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8
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Libman-Sacks endocarditis and embolic cerebrovascular disease. JACC Cardiovasc Imaging 2014; 6:973-83. [PMID: 24029368 DOI: 10.1016/j.jcmg.2013.04.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/18/2013] [Accepted: 04/23/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE). BACKGROUND A cardioembolic pathogenesis of SLE CVD manifested as: 1) neuropsychiatric systemic lupus erythematosus (NPSLE), including stroke and transient ischemic attacks (TIA); 2) neurocognitive dysfunction; and 3) magnetic resonance imaging of focal brain lesions has not been established. METHODS A 6-year study of 30 patients with acute NPSLE (27 women, 38 ± 12 years of age), 46 age- and sex-matched SLE controls without NPSLE (42 women, 36 ± 12 years of age), and 26 age- and sex-matched healthy controls (22 women, 34 ± 11 years of age) who underwent clinical and laboratory evaluations, transesophageal echocardiography, carotid duplex ultrasound, transcranial Doppler ultrasound, neurocognitive testing, and brain magnetic resonance imaging/magnetic resonance angiography. Patients with NPSLE were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months. RESULTS Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p ≤ 0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more strokes/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p ≤ 0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (odds ratio [OR]: 13.4; p < 0.001), neurocognitive dysfunction (OR: 8.0; p = 0.01), brain lesions (OR: 5.6; p = 0.004), and all 3 outcomes combined (OR: 7.5; p < 0.001). Follow-up re-evaluations in 18 of 23 (78%) surviving patients with NPSLE demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p ≤ 0.04). Finally, patients with vegetations had reduced event-free survival time to stroke/TIA, cognitive disability, or death (p = 0.007). CONCLUSIONS The presence of Libman-Sacks endocarditis in patients with SLE was associated with a higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.
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Zardi E, Vernieri F, Navarini L, Taccone A, Sambataro G, Alemanno P, Margiotta D, Afeltra A. Systemic Lupus Erythematosus Patients with and without Neuropsychiatric Manifestations: A Neck and Transcranial Duplex Sonography Study. Int J Immunopathol Pharmacol 2012; 25:1157-65. [DOI: 10.1177/039463201202500434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neuropsychiatric manifestations are not rarely associated with systemic lupus erythematosus (SLE). Magnetic resonance angiography and positron emission tomography can provide excellent images of cerebral perfusion and metabolism whereas information is still lacking on a possible diagnostic role of ultrasound. In this study we aim to assess whether duplex sonography of neck and intracranial vessels may be useful in distinguishing patients with and without neuropsychiatric SLE (NPSLE). Neck and transcranial duplex sonography was performed by a single operator on 33 women affected by SLE (mean age ± SD: 47.69±8.17 years) and on 15 healthy control subjects. Nineteen patients presented NPSLE. Pulsatility and resistivity indices (PI and RI) were automatically calculated by the ultrasound instrument in internal carotid (ICA) and middle cerebral artery (MCA), on both sides, according to standard methods. No significant haemodynamic differences were found in mean and median PI and RI values of ICA and MCA comparing SLE with NPSLE patients and with healthy control subjects. No correlation was found between MCA and ICA parameters in the same group of patients. Duplex sonography of cerebral vessels is unable to distinguish SLE and NPSLE patients. Heterogeneity of causes in the pathogenesis of NPSLE and the different vascular adaptation of cerebral macrocirculation as opposed to cerebral microcirculation may represent possible reasons that explain the inability of ultrasound to differentiate SLE patients from NPSLE patients.
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Affiliation(s)
- E.M. Zardi
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - F. Vernieri
- Clinical Neurology, University “Campus Bio-Medico” of Rome, Italy
| | - L. Navarini
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - A. Taccone
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - G. Sambataro
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - P. Alemanno
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - D. Margiotta
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
| | - A. Afeltra
- Department of Clinical Medicine and Rheumatology, University “Campus Bio-Medico” of Rome, Italy
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10
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Microembolic signals in systemic lupus erythematosus and other cerebral small vessel diseases. J Neurol 2009; 257:503-8. [DOI: 10.1007/s00415-009-5421-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 11/29/2009] [Accepted: 12/02/2009] [Indexed: 11/25/2022]
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