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Cui J, Yang J, Wang Y, Ma M, Zhang N, Wang R, Zhou B, Meng C, Yang P, Yang J, Xu L, Tan G, Liu L, Zhen J, Guo L, Liu X. Automatic segmentation of hemispheric CSF on MRI using deep learning: Quantifying cerebral edema following large hemispheric infarction. Heliyon 2024; 10:e26673. [PMID: 38463867 PMCID: PMC10920171 DOI: 10.1016/j.heliyon.2024.e26673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 01/27/2024] [Accepted: 02/16/2024] [Indexed: 03/12/2024] Open
Abstract
Background and objective Cerebral edema (CED) is a serious complication of acute ischemic stroke (AIS), especially in patients with large hemispheric infarction (LHI). Herein, a deep learning-based approach is implemented to extract CSF from T2-Weighted Imaging (T2WI) and evaluate the relationship between quantified cerebrospinal fluid and outcomes. Methods Patients with acute LHI who underwent magnetic resonance imaging (MRI) were included. We used a deep learning algorithm to segment the CSF from T2WI. The hemispheric CSF ratio was calculated to evaluate its relationship with the degree of brain edema and prognosis in patients with LHI. Results For the 93 included patients, the left and right cerebrospinal fluid regions were automatically extracted with a mean Dice similarity coefficient of 0.830. Receiver operating characteristic analysis indicated that hemispheric CSF ratio was an accurate marker for qualitative severe cerebral edema (area under receiver-operating-characteristic curve 0.867 [95% CI, 0.781-0.929]). Multivariate logistic regression analysis of functional prognosis showed that previous stroke (OR = 5.229, 95% CI 1.013-26.984), ASPECT≤6 (OR = 13.208, 95% CI 1.136-153.540) and low hemispheric CSF ratio (OR = 0.966, 95% CI 0.937-0.997) were significantly associated with higher chances for unfavorable functional outcome in patients with LHI. Conclusions Automated assessment of CSF volume provides an objective biomarker of cerebral edema that can be leveraged to quantify the degree of cerebral edema and confirm its predictive effect on outcomes after LHI.
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Affiliation(s)
- Junzhao Cui
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingyi Yang
- Department of Data Center, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ye Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Meixin Ma
- University of California, Berkeley College of Letters and Science, US
| | - Ning Zhang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rui Wang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Biyi Zhou
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chaoyue Meng
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianing Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Xu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guojun Tan
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lidou Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Junli Zhen
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Li Guo
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaoyun Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Neurology, The First Hospital of Hebei Medical University, Shijiazhuang, China
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Zhang J, Kowsalya R. Daidzein Ameliorates Cerebral Ischemic-reperfusion Induced Neuroinflammation in Wistar Rats via Inhibiting NF-κB Signaling Pathway. Pharmacogn Mag 2023. [DOI: 10.1177/09731296221137378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Background Cerebral ischemia is a condition of acute brain damage due to the depletion of oxygenated blood supply to cerebral tissues. Daidzein is an isoflavonoid predominantly present in soya, Pueraria species, and red cloves. Traditional Chinese medicine utilizes daidzein to alleviate diseases such as inflammation, hyperglycemia, gastric diseases, allergies and aches. The neuroprotective effect of daidzein on cerebral ischemic conditions and its mechanism of action was not yet elucidated. Materials and Methods 24 healthy male adult Wistar rats were grouped into four and the control rats were sham-operated, cerebral ischemic-reperfusion induced rats subjected to middle cerebral artery occlusion (MCAO). Low- and high-dose daidzein rats were treated with 25 and 50 mg/kg daidzein respectively for 7 consecutive days before the induction of cerebral ischemic reperfusion. On completion of treatment, the rats were assessed for neurological deficit scoring and then euthanized for further analysis. The percentage of brain water content and cerebral infarct was evaluated. The ability of daidzein on preventing oxidative stress-induced damage was assessed by quantifying lipid peroxidation and antioxidant levels. The neuroprotective Daidzein was evaluated by measuring the acetylcholinesterase activity and brain ATP levels. The anti-inflammatory role of Daidzein was measured by quantifying the nitric oxide (NO) and inflammatory cytokines. Further, the anti-ischemic role of Daidzein was confirmed by estimating nuclear factor-kappa B (NF-κB) p65 and Caspase 3 levels. Results Daidzein treatment significantly prevented brain edema and cerebral infarction and neurological deficit in cerebral I/R injured rats. It also scavenged the free radicals and prevented the decline in antioxidant levels of ischemic rats. Daidzein decreased the acetylcholinesterase activity, NO, and inflammatory and significantly increased the brain ATP levels signifying its neuroprotective role in ischemic-induced rats. The reduction in the levels of NF-κB p65 and Caspase 3 confirms daidzein prevents neuroinflammation and neuronal apoptosis in ischemic rats. Conclusion Overall our analysis confirms daidzein is a potent neuroprotective drug which can effectively inhibit postischemic complications.
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Affiliation(s)
- Jie Zhang
- Department of Neurosurgery, Laizhou City people’s Hospital, Wuli Street, Laizhou City, Shandong Province, China
| | - Ramalingam Kowsalya
- Vivekanandha College of Arts and Sciences for Women (Autonomous), Elayampalayam, Tiruchengode, Namakkal, Tamil Nadu, India
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The Differences of Metabolites in Different Parts of the Brain Induced by Shuxuetong Injection against Cerebral Ischemia-Reperfusion and Its Corresponding Mechanism. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:9465095. [PMID: 35815276 PMCID: PMC9259222 DOI: 10.1155/2022/9465095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Abstract
Ischemic stroke is often associated with a large disease burden. The existence of ischemia-reperfusion injury brings great challenges to the treatment of ischemic stroke. The purpose of this study was to explore the differences of metabolites in different parts of the brain induced by Shuxuetong injection against cerebral ischemia-reperfusion and to extend the corresponding mechanism. The rats were modeled by transient middle cerebral artery occlusion (t-MCAO) operation, and the success of modeling was determined by neurological function score and TTC staining. UPLC-Q/TOF-MS metabolomics technique and multivariate statistical analysis were used to analyze the changes and differences of metabolites in the cortex and hippocampus of cerebral ischemia-reperfusion rats. Compared with the model group, the neurological function score and cerebral infarction volume of the Shuxuetong treatment group were significantly different. There were differences and changes in the metabolic distribution of the cortex and hippocampus in each group, the distribution within the group was relatively concentrated. The separation trend between the groups was obvious, and the distribution of the Shuxuetong treatment group was similar to that of the sham operation group. We identified 13 metabolites that were differentially expressed in the cortex, including glutamine, dihydroorotic acid, and glyceric acid. We also found five differentially expressed metabolites in the hippocampus, including glutamic acid and fumaric acid. The common metabolic pathways of Shuxuetong on the cortex and hippocampus were D-glutamine and D-glutamate metabolism and nitrogen metabolism, which showed inhibition of cortical glutamine and promotion of hippocampal glutamic acid. Specific pathways of Shuxuetong enriched in the cortex included glyoxylate and dicarboxylate metabolism and pyrimidine metabolism, which showed inhibition of glyceric acid and dihydroorotic acid. Specific pathways of Shuxuetong enriched in the hippocampus include arginine biosynthesis and citrate cycle (TCA cycle), which promotes fumaric acid. Shuxuetong injection can restore and adjust the metabolic disorder of the cortex and hippocampus in cerebral ischemia-reperfusion rats. The expression of Shuxuetong in different parts of the brain is different and correlated.
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Decompressive Craniectomy for Infarction and Intracranial Hemorrhages. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Conti E, Piccardi B, Sodero A, Tudisco L, Lombardo I, Fainardi E, Nencini P, Sarti C, Allegra Mascaro AL, Baldereschi M. Translational Stroke Research Review: Using the Mouse to Model Human Futile Recanalization and Reperfusion Injury in Ischemic Brain Tissue. Cells 2021; 10:3308. [PMID: 34943816 PMCID: PMC8699609 DOI: 10.3390/cells10123308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 12/20/2022] Open
Abstract
The approach to reperfusion therapies in stroke patients is rapidly evolving, but there is still no explanation why a substantial proportion of patients have a poor clinical prognosis despite successful flow restoration. This issue of futile recanalization is explained here by three clinical cases, which, despite complete recanalization, have very different outcomes. Preclinical research is particularly suited to characterize the highly dynamic changes in acute ischemic stroke and identify potential treatment targets useful for clinical translation. This review surveys the efforts taken so far to achieve mouse models capable of investigating the neurovascular underpinnings of futile recanalization. We highlight the translational potential of targeting tissue reperfusion in fully recanalized mouse models and of investigating the underlying pathophysiological mechanisms from subcellular to tissue scale. We suggest that stroke preclinical research should increasingly drive forward a continuous and circular dialogue with clinical research. When the preclinical and the clinical stroke research are consistent, translational success will follow.
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Affiliation(s)
- Emilia Conti
- Neuroscience Institute, National Research Council, Via G. Moruzzi 1, 56124 Pisa, Italy; (E.C.); (A.L.A.M.)
- European Laboratory for Non-Linear Spectroscopy, Via Nello Carrara 1, 50019 Sesto Fiorentino, Italy
| | - Benedetta Piccardi
- Neurofarba Department, University of Florence, Via G. Pieraccini 6, 50139 Florence, Italy; (A.S.); (L.T.); (C.S.)
| | - Alessandro Sodero
- Neurofarba Department, University of Florence, Via G. Pieraccini 6, 50139 Florence, Italy; (A.S.); (L.T.); (C.S.)
| | - Laura Tudisco
- Neurofarba Department, University of Florence, Via G. Pieraccini 6, 50139 Florence, Italy; (A.S.); (L.T.); (C.S.)
| | - Ivano Lombardo
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (I.L.); (E.F.)
| | - Enrico Fainardi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 50, 50134 Florence, Italy; (I.L.); (E.F.)
| | - Patrizia Nencini
- Stroke Unit, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy;
| | - Cristina Sarti
- Neurofarba Department, University of Florence, Via G. Pieraccini 6, 50139 Florence, Italy; (A.S.); (L.T.); (C.S.)
| | - Anna Letizia Allegra Mascaro
- Neuroscience Institute, National Research Council, Via G. Moruzzi 1, 56124 Pisa, Italy; (E.C.); (A.L.A.M.)
- European Laboratory for Non-Linear Spectroscopy, Via Nello Carrara 1, 50019 Sesto Fiorentino, Italy
| | - Marzia Baldereschi
- Neuroscience Institute, National Research Council, Via Madonna del Piano 10, 50019 Sesto Fiorentino, Italy;
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Comparison of Accuracy of Arrival-Time-Insensitive and Arrival-Time-Sensitive CTP Algorithms for Prediction of Infarct Tissue Volumes. Sci Rep 2020; 10:9252. [PMID: 32518270 PMCID: PMC7283304 DOI: 10.1038/s41598-020-66041-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/14/2020] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to compare the performance of arrival-time-insensitive (ATI) and arrival-time-sensitive (ATS) computed tomography perfusion (CTP) algorithms in Philips IntelliSpace Portal (v9, ISP) and to investigate optimal thresholds for ATI regarding the prediction of final infarct volume (FIV). Retrospective, single-center study with 54 patients (mean 67.0 ± 13.1 years, 68.5% male) who received Stroke-CT/CTP-imaging between 2010 and 2018 with occlusion of the middle cerebral artery in the M1-/proximal M2-segment or terminal internal carotid artery. FIV was determined on short-term follow-up imaging in two patient groups: A) not attempted or failed mechanical thrombectomy (MT) and B) successful MT. ATS (default settings) and ATI (full-range of threshold settings regarding FIV prediction) maps were coregistered in 3D with FIV using voxel-wise overlap measurement. Based on an average imaging follow-up of 2.6 ± 2.1 days, the estimation regarding penumbra (group A, ATI: r = 0.63/0.69, ATS: r = 0.64) and infarct core (group B, ATI: r = 0.60/0.68, ATS: r = 0.63) was slightly higher in ATI but the effect was not significant (p > 0.05). Regarding ATI, Tmax (AUC 0.9) was the best estimator of the penumbra (group A), CBF relative to the contralateral hemisphere (AUC 0.80) showed the best estimation of the infarct core (group B). There was a broad range of thresholds of optimal ATI settings in both groups. Prediction of FIV with ATI was slightly better compared to ATS. However, this difference was not significant. Since ATI showed a broad range of optimal thresholds, exact thresholds regarding the ATI algorithm should be evaluated in further prospective, clinical studies.
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Thorén M, Azevedo E, Dawson J, Egido JA, Falcou A, Ford GA, Holmin S, Mikulik R, Ollikainen J, Wahlgren N, Ahmed N. Predictors for Cerebral Edema in Acute Ischemic Stroke Treated With Intravenous Thrombolysis. Stroke 2017; 48:2464-2471. [PMID: 28775140 DOI: 10.1161/strokeaha.117.018223] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral edema (CED) is a severe complication of acute ischemic stroke. There is uncertainty regarding the predictors for the development of CED after cerebral infarction. We aimed to determine which baseline clinical and radiological parameters predict development of CED in patients treated with intravenous thrombolysis. METHODS We used an image-based classification of CED with 3 degrees of severity (less severe CED 1 and most severe CED 3) on postintravenous thrombolysis imaging scans. We extracted data from 42 187 patients recorded in the SITS International Register (Safe Implementation of Treatments in Stroke) during 2002 to 2011. We did univariate comparisons of baseline data between patients with or without CED. We used backward logistic regression to select a set of predictors for each CED severity. RESULTS CED was detected in 9579/42 187 patients (22.7%: 12.5% CED 1, 4.9% CED 2, 5.3% CED 3). In patients with CED versus no CED, the baseline National Institutes of Health Stroke Scale score was higher (17 versus 10; P<0.001), signs of acute infarct was more common (27.9% versus 19.2%; P<0.001), hyperdense artery sign was more common (37.6% versus 14.6%; P<0.001), and blood glucose was higher (6.8 versus 6.4 mmol/L; P<0.001). Baseline National Institutes of Health Stroke Scale, hyperdense artery sign, blood glucose, impaired consciousness, and signs of acute infarct on imaging were independent predictors for all edema types. CONCLUSIONS The most important baseline predictors for early CED are National Institutes of Health Stroke Scale, hyperdense artery sign, higher blood glucose, decreased level of consciousness, and signs of infarct at baseline. The findings can be used to improve selection and monitoring of patients for drug or surgical treatment.
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Affiliation(s)
- Magnus Thorén
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.).
| | - Elsa Azevedo
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jesse Dawson
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jose A Egido
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Anne Falcou
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Gary A Ford
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Staffan Holmin
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Robert Mikulik
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Jyrki Ollikainen
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Nils Wahlgren
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
| | - Niaz Ahmed
- From the Department of Neurology (M.T., N.A.), and Department of Neuroradiology (S.H.), Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Sweden (N.W.); Department of Neurology, São João Hospital Center, and Department of Clinical Neurosciences and Mental Health, Faculty of Medicine of University of Porto, Portugal (E.A.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, United Kingdom (J.D.); Stroke Unit, Neurology Department, Hospital Clínico San Carlos, Madrid, Spain (J.A.E.); Emergency Department Stroke Unit, Policlinico Umberto I Hospital, "Sapienza" University of Rome, Italy (A.F.); Acute Stroke Service, Oxford University Hospitals NHS Foundation Trust, and Radcliffe Department of Medicine, Oxford University, United Kingdom (G.A.F.); International Clinical Research Center and Department of Neurology, St Anne's University Hospital Brno, and Faculty of Medicine, Masaryk University, Czech Republic (R.M.); and Department of Neurology, Tampere University Hospital, Finland (J.O.)
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Schneider H, Krüger P, Algra A, Hofmeijer J, van der Worp HB, Jüttler E, Vahedi K, Schackert G, Reichmann H, Puetz V. No benefits of hypothermia in patients treated with hemicraniectomy for large ischemic stroke. Int J Stroke 2017; 12:732-740. [PMID: 28350280 DOI: 10.1177/1747493017694388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Space-occupying middle cerebral artery brain infarcts are associated with the development of brain edema, which may lead to cerebral herniation and death despite early hemicraniectomy. Aims To evaluate the benefit of therapeutic hypothermia in patients with space-occupying cerebral infarction treated with hemicraniectomy within 48 h of stroke onset. Methods Patients aged 18-60 years with space-occupying cerebral infarction treated with hemicraniectomy within 48 h and hypothermia (33-34°C) were selected from a single university hospital between 2001 and 2010 (n = 53). Patients treated with hemicraniectomy alone served as comparison group (n = 58), originating from three randomized controlled trials evaluating the effects of early decompressive surgery (DECIMAL, DESTINY, HAMLET). Primary outcome was the score on the modified Rankin scale at 12 months dichotomized between modified Rankin scale 0-3 and modified Rankin scale 4-6. Secondary outcome measures were modified Rankin scale score 0-4 and survival. Risk ratios were adjusted with Poisson regression. Results Mean patient age was 48 years. Median time from stroke onset to hemicraniectomy was 23.5 h in both treatment groups. Treatment with hypothermia had no effect on the primary outcome (modified Rankin scale 0-3 versus 4-6 (13/53 (25%) versus 24/58 (41%)); adjusted risk ratio 0.66, 95% confidence interval 0.38-1.13). Fewer patients treated with hypothermia had a modified Rankin scale score of 0-4 (21/53 (40%) versus 42/58 (72%); adjusted risk ratio 0.53, 95% confidence interval 0.37-0.76) and fewer patients survived (26/53 (49%) versus 46/58 (79%); adjusted risk ratio 0.60, 95% confidence interval 0.44-0.82). Conclusions In patients with space-occupying cerebral infarction, treatment with hypothermia had no additional benefit on functional outcome compared with treatment with hemicraniectomy alone.
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Affiliation(s)
- Hauke Schneider
- 1 Department of Neurology and Dresden University Stroke Center, Dresden University of Technology, Dresden, Germany
| | - Philipp Krüger
- 2 Department of Anesthesiology, Klinikum Dortmund gGmbH, Dortmund, Germany
| | - Ale Algra
- 3 Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands.,4 Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - H Bart van der Worp
- 3 Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Eric Jüttler
- 6 Department of Neurology, Ostalb-Klinikum Aalen, Aalen, Germany.,7 Department of Neurology, University of Ulm, Ulm, Germany
| | - Katayoun Vahedi
- 8 Neurology Centre, Générale de Sante, Hôpital Privé d'Antony, Antony, and AP-HP, Hôpital Lariboisière, Paris, France
| | - Gabriele Schackert
- 9 Department of Neurosurgery, Dresden University of Technology, Dresden, Germany
| | - Heinz Reichmann
- 1 Department of Neurology and Dresden University Stroke Center, Dresden University of Technology, Dresden, Germany
| | - Volker Puetz
- 1 Department of Neurology and Dresden University Stroke Center, Dresden University of Technology, Dresden, Germany
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Jeong HY, Chang JY, Yum KS, Hong JH, Jeong JH, Yeo MJ, Bae HJ, Han MK, Lee K. Extended Use of Hypothermia in Elderly Patients with Malignant Cerebral Edema as an Alternative to Hemicraniectomy. J Stroke 2016; 18:337-343. [PMID: 27488978 PMCID: PMC5066429 DOI: 10.5853/jos.2016.00276] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 01/19/2023] Open
Abstract
Background and Purpose The use of decompressive hemicraniectomy (DHC) for the treatment of malignant cerebral edema can decrease mortality rates. However, this benefit is not sufficient to justify its use in elderly patients. We investigated the effects of therapeutic hypothermia (TH) on safety, feasibility, and functional outcomes in elderly patients with malignant middle cerebral artery (MCA) infarcts. Methods Elderly patients 60 years of age and older with infarcts affecting more than two-thirds of the MCA territory were included. Patients who could not receive DHC were treated with TH. Hypothermia was started within 72 hours of symptom onset and was maintained for a minimum of 72 hours with a target temperature of 33°C. Modified Rankin Scale (mRS) scores at 3 months following treatment and complications of TH were used as functional outcomes. Results Eleven patients with a median age of 76 years and a median National Institutes of Health Stroke Scale score of 18 were treated with TH. The median time from symptom onset to initiation of TH was 30.3±23.0 hours and TH was maintained for a median of 76.7±57.1 hours. Shivering (100%) and electrolyte imbalance (82%) were frequent complications. Two patients died (18%). The mean mRS score 3 months following treatment was 4.9±0.8. Conclusions Our results suggest that extended use of hypothermia is safe and feasible for elderly patients with large hemispheric infarctions. Hypothermia may be considered as a therapeutic alternative to DHC in elderly individuals. Further studies are required to validate our findings.
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Affiliation(s)
- Han-Yeong Jeong
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jun-Young Chang
- Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Kyu Sun Yum
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jin-Heon Jeong
- Department of Intensive Care medicine and Neurology, Dong-A University Hospital, Busan, Korea
| | - Min-Ju Yeo
- Department of Neurology, Chungbuk National University, Chungju, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The University of Texas Houston Medical School and Memorial Hermann Texas Medical Center, Houston, United States
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Godoy D, Piñero G, Cruz-Flores S, Alcalá Cerra G, Rabinstein A. Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2013.02.009] [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] Open
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von Olnhausen O, Thorén M, von Vogelsang AC, Svensson M, Schechtmann G. Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Acta Neurochir (Wien) 2016; 158:865-72; discussion 873. [PMID: 26923797 DOI: 10.1007/s00701-016-2749-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The mortality rate of patients with brain oedema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention. Surgical treatment with ipsilateral decompressive hemicraniectomy (DHC) has been shown to dramatically improve survival rates. DHC currently lacks established inclusion criteria and additional research is needed to assess the impact of prognostic factors on functional outcome. The aim of this study was to assess the impact of prognostic factors on functional outcome. METHOD A retrospective cohort study was carried out including 46 patients who underwent DHC at the Karolinska University Hospital between 2004 and 2014. The maximum time to surgery was 5 days after symptom debut. The primary endpoint was a dichotomised score on the modified Rankin Scale (mRS) 3 months after surgery, with favourable outcome defined as mRS ≤ 4. RESULTS When the study population was dichotomised according to the primary endpoint, a significant difference between the groups was seen in preoperative Glasgow Coma Score (GCS), blood glucose levels and the infarction's involvement of the basal ganglia (p < 0.05). In a logistic regression model, preoperative GCS contributed significantly with a 59.6 % increase in the probability of favourable outcome for each point gained in preoperative GCS (p = 0.035). CONCLUSIONS The results indicate that preoperative GCS, blood glucose and the infarction's involvement of the basal ganglia are strong predictors of clinical outcome. These factors should be considered when assessing the probable outcome of DHC, and additional research based on these factors may contribute to improved inclusion criteria for DHC.
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12
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Neugebauer H, Jüttler E, Mitchell P, Hacke W. Decompressive Craniectomy for Infarction and Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Early Implementation of THAM for ICP Control: Therapeutic Hypothermia Avoidance and Reduction in Hypertonics/Hyperosmotics. Case Rep Crit Care 2014; 2014:139342. [PMID: 25544901 PMCID: PMC4273533 DOI: 10.1155/2014/139342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 11/18/2014] [Indexed: 11/26/2022] Open
Abstract
Background. Tromethamine (THAM) has been demonstrated to reduce intracranial pressure (ICP). Early consideration for THAM may reduce the need for other measures for ICP control. Objective. To describe 4 cases of early THAM therapy for ICP control and highlight the potential to avoid TH and paralytics and achieve reduction in sedation and hypertonic/hyperosmotic agent requirements. Methods. We reviewed the charts of 4 patients treated with early THAM for ICP control. Results. We identified 2 patients with aneurysmal subarachnoid hemorrhage (SAH) and 2 with traumatic brain injury (TBI) receiving early THAM for ICP control. The mean time to initiation of THAM therapy was 1.8 days, with a mean duration of 5.3 days. In all patients, after 6 to 12 hours of THAM administration, ICP stability was achieved, with reduction in requirements for hypertonic saline and hyperosmotic agents. There was a relative reduction in mean hourly hypertonic saline requirements of 89.1%, 96.1%, 82.4%, and 97.0% for cases 1, 2, 3, and 4, respectively, comparing pre- to post-THAM administration. Mannitol, therapeutic hypothermia, and paralytics were avoided in all patients. Conclusions. Early administration of THAM for ICP control could potentially lead to the avoidance of other ICP directed therapies. Prospective studies of early THAM administration are warranted.
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Zweckberger K, Juettler E, Bösel J, Unterberg WA. Surgical Aspects of Decompression Craniectomy in Malignant Stroke: Review. Cerebrovasc Dis 2014; 38:313-23. [DOI: 10.1159/000365864] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/02/2014] [Indexed: 11/19/2022] Open
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Schellinger PD, Shuaib A, Köhrmann M, Liebeskind DS, Jovin T, Hammer MD, Sen S, Huang DY, Solander S, Gupta R, Leker RR, Saver JL. Reduced mortality and severe disability rates in the SENTIS trial. AJNR Am J Neuroradiol 2013; 34:2312-6. [PMID: 23828106 DOI: 10.3174/ajnr.a3613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial. MATERIALS AND METHODS The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey. RESULTS All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates. CONCLUSIONS There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.
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Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: Complications, treatment and outcome. Clin Neurol Neurosurg 2013; 115:863-9. [DOI: 10.1016/j.clineuro.2013.04.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/23/2013] [Accepted: 04/07/2013] [Indexed: 11/25/2022]
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Neugebauer H, Witsch J, Zweckberger K, Jüttler E. Space-occupying cerebellar infarction: complications, treatment, and outcome. Neurosurg Focus 2013; 34:E8. [DOI: 10.3171/2013.2.focus12363] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Space-occupying brain edema is a frequent and one of the most dreaded complications in ischemic cerebellar stroke. Because the tight posterior fossa provides little compensating space, any space-occupying lesion can lead to life-threatening complications through brainstem compression or compression of the fourth ventricle and subsequent hydrocephalus, both of which may portend transtentorial/transforaminal herniation. Patients with large cerebellar infarcts should be treated and monitored very early on in an experienced stroke unit or (neuro)intensive care unit. The general treatment of ischemic cerebellar infarction does not differ from that of supratentorial ischemic strokes. Treatment strategies for space-occupying edema include pharmacological antiedema and intracranial pressure–lowering therapies, ventricular drainage by means of an extraventricular drain, and suboccipital decompressive surgery, with or without resection of necrotic tissue. Timely escalation of treatment is crucial and should be guided by clinical and neuroradiological rationales. Patients in a coma after hydrocephalus and/or local brainstem compression may also benefit from more aggressive surgical treatment, as long as the conditions are reversible. Contrary to the general belief that outcome in survivors of space-occupying cerebellar stroke is usually good, recent studies suggest that for many of these patients, the long-term outcome is not good. In particular, advanced age and additional brainstem infarction seem to be predictors for poor outcome. Further trials are necessary to investigate these findings systematically and provide better selection criteria to help guide decisions about surgical therapies, which should always be carried out in close cooperation among neurointensive care physicians, neurologists, and neurosurgeons.
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Affiliation(s)
| | - Jens Witsch
- 2Department of Neurology, Charité University Medicine Berlin, Campus Virchow Klinikum, Berlin; and
| | - Klaus Zweckberger
- 3Department of Neurosurgery, Ruprecht-Karl-University Heidelberg, Germany
| | - Eric Jüttler
- 1Department of Neurology, Rehabilitation and University Hospital Ulm
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Godoy D, Piñero G, Cruz-Flores S, Alcalá Cerra G, Rabinstein A. Malignant hemispheric infarction of the middle cerebral artery. Diagnostic considerations and treatment options. Neurologia 2013; 31:332-43. [PMID: 23601756 DOI: 10.1016/j.nrl.2013.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 02/19/2013] [Accepted: 02/25/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Malignant hemispheric infarction (MHI) is a specific and devastating type of ischemic stroke. It usually affects all or part of the territory of the middle cerebral artery although its effects may extend to other territories as well. Its clinical outcome is frequently catastrophic when only conventional medical treatment is applied. OBJECTIVE The purpose of this review is to analyse the available scientific evidence on the treatment of this entity. DEVELOPMENT MHI is associated with high morbidity and mortality. Its clinical characteristics are early neurological deterioration and severe hemispheric syndrome. Its hallmark is the development of space-occupying cerebral oedema between day 1 and day 3 after symptom onset. The mass effect causes displacement, distortion, and herniation of brain structures even when intracranial hypertension is initially absent. Until recently, MHI was thought to be fatal and untreatable because mortality rates with conventional medical treatment could exceed 80%. In this unfavourable context, decompressive hemicraniectomy has re-emerged as a therapeutic alternative for selected cases, with reported decreases in mortality ranging between 15% and 40%. CONCLUSIONS In recent years, several randomised clinical trials have demonstrated the benefit of decompressive hemicraniectomy in patients with MHI. This treatment reduces mortality in addition to improving functional outcomes.
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Affiliation(s)
- D Godoy
- Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina; Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina.
| | - G Piñero
- Unidad de Terapia Intensiva, Hospital Municipal Leonidas Lucero, Bahía Blanca, Buenos Aires, Argentina
| | - S Cruz-Flores
- Department of Neurology & Psychiatry, Saint Louis University School of Medicine, Saint Louis, Estados Unidos
| | - G Alcalá Cerra
- Facultad de Medicina, Universidad de Cartagena, Cartagena, Colombia
| | - A Rabinstein
- Neuroscience ICU and Regional Acute Stroke Program Mayo Clinic, Rochester, MN, Estados Unidos
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Hemicraniectomy in the management of space-occupying ischemic stroke. J Clin Neurosci 2013; 20:6-12. [DOI: 10.1016/j.jocn.2012.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 01/04/2023]
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Neugebauer H, Heuschmann PU, Jüttler E. DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY - Registry (DESTINY-R): design and protocols. BMC Neurol 2012; 12:115. [PMID: 23031451 PMCID: PMC3517444 DOI: 10.1186/1471-2377-12-115] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 09/22/2012] [Indexed: 11/30/2022] Open
Abstract
Background Randomized controlled trials (RCT) on the treatment of severe space-occupying infarction of the middle cerebral artery (malignant MCA infarction) showed that early decompressive hemicraniectomy (DHC) is life saving and improves outcome without promoting most severe disablity in patients aged 18–60 years. It is, however, unknown whether the results obtained in the randomized trials are reproducible in a broader population in and apart from an academical setting and whether hemicraniectomy has been implemented in clinical practice as recommended by national and international guidelines. In addition, they were not powered to answer further relevant questions, e.g. concerning the selection of patients eligible for and the timing of hemicraniectomy. Other important issues such as the acceptance of disability following hemicraniectomy, the existence of specific prognostic factors, the value of conservative therapeutic measures, and the overall complication rate related to hemicraniectomy have not been sufficiently studied yet. Methods/Design DESTINY-R is a prospective, multicenter, open, controlled registry including a 12 months follow-up. The only inclusion criteria is unilateral ischemic MCA stroke affecting more than 50% of the MCA-territory. The primary study hypothesis is to confirm the results of the RCT (76% mRS ≤ 4 after 12 months) in the subgroup of patients additionally fulfilling the inclusion cirteria of the RCT in daily routine. Assuming a calculated proportion of 0.76 for successes and a sample size of 300 for this subgroup, the width of the 95% CI, calculated using Wilson's method, will be 0.096 with the lower bound 0.709 and the upper bound 0.805. Discussion The results of this study will provide information about the effectiveness of DHC in malignant MCA infarction in a broad population and a real-life situation in addition to and beyond RCT. Further prospectively obtained data will give crucial information on open questions and will be helpful in the plannig of upcomming treatment studies. Trial registration (ICTRP and DRKS): DRKS00000624
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Affiliation(s)
- Hermann Neugebauer
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Aktuelle Registerstudien beim akuten ischämischen Schlaganfall. DER NERVENARZT 2012; 83:1270-4. [DOI: 10.1007/s00115-012-3535-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ji YB, Wu YM, Ji Z, Song W, Xu SY, Wang Y, Pan SY. Interrupted intracarotid artery cold saline infusion as an alternative method for neuroprotection after ischemic stroke. Neurosurg Focus 2012; 33:E10. [DOI: 10.3171/2012.5.focus1215] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Intracarotid artery cold saline infusion (ICSI) is an effective method for protecting brain tissue, but its use is limited because of undesirable secondary effects, such as severe decreases in hematocrit levels, as well as its relatively brief duration. In this study, the authors describe and investigate the effects of a novel ICSI pattern (interrupted ICSI) relative to the traditional method (uninterrupted ICSI).
Methods
Ischemic strokes were induced in 85 male Sprague-Dawley rats by occluding the middle cerebral artery for 3 hours using an intraluminal filament. Uninterrupted infusion groups received an infusion at 15 ml/hour for 30 minutes continuously. The same infusion speed was used in the interrupted infusion groups, but the whole duration was divided into trisections, and there was a 20-minute interval without infusion between sections. Forty-eight hours after reperfusion, H & E and silver nitrate staining were utilized for morphological assessment. Infarct sizes and brain water contents were determined using H & E staining and the dry-wet weight method, respectively. Levels of neuron-specific enolase (NSE), S100β protein, and matrix metalloproteinase 9 (MMP-9) in the serum were determined using enzyme-linked immunosorbent assay. Neurological deficits were also evaluated.
Results
Histology showed that interrupted ICSI did not affect neurons or fibers in rat brains, which suggests that this method is safe for brain tissues with ischemia. The duration of hypothermia induced by interrupted ICSI was longer than that induced via the traditional method, and the decrease in hematocrit levels was less pronounced. There were no differences in infarct size or brain water content between uninterrupted and interrupted ICSI groups, but neuron-specific enolase and matrix metalloproteinase 9 serum levels were more reduced after interrupted ICSI than after the traditional method.
Conclusions
Interrupted ICSI is a safe method. Compared with traditional ICSI, the interrupted method has a longer duration of hypothermia and less effect on hematocrit and offers more potentially improved neuroprotection, thereby making it more attractive as an infusion technique in the clinic.
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Dénes A, Ferenczi S, Kovács KJ. Systemic inflammatory challenges compromise survival after experimental stroke via augmenting brain inflammation, blood- brain barrier damage and brain oedema independently of infarct size. J Neuroinflammation 2011; 8:164. [PMID: 22114895 PMCID: PMC3235982 DOI: 10.1186/1742-2094-8-164] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 11/24/2011] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Systemic inflammation impairs outcome in stroke patients and experimental animals via mechanisms which are poorly understood. Circulating inflammatory mediators can activate cerebrovascular endothelium or glial cells in the brain and impact on ischaemic brain injury. One of the most serious early clinical complications of cerebral ischaemia is brain oedema, which compromises survival in the first 24-48 h. It is not understood whether systemic inflammatory challenges impair outcome after stroke by increasing brain injury only or whether they have direct effects on brain oedema, cerebrovascular inflammation and blood-brain barrier damage. METHODS We used two different systemic inflammatory stimuli, acute endotoxin treatment and anaphylaxis to study mechanisms of brain injury after middle cerebral artery occlusion (MCAo). Ischaemic brain injury, blood-brain barrier damage and oedema were analysed by histological techniques. Systemic cytokine responses and inflammatory changes in the brain were analysed by cytometric bead array, immunofluorescence, in situ hibridization and quantitative real-time PCR. RESULTS Systemic inflammatory challenges profoundly impaired survival in the first 24 h after experimental stroke in mice, independently of an increase in infarct size. Systemic lipopolysaccharide (LPS) dose-dependently increased mortality (50-100%) minutes to hours after cerebral ischaemia. Acute anaphylactic challenge in ovalbumin-sensitised mice affected stroke more seriously when induced via intraperitoneal administration compared to intravenous. Both LPS and anaphylaxis induced inflammatory changes in the blood and in the brain prior to experimental stroke. Plasma cytokine levels were significantly higher after LPS, while increased IL-10 levels were seen after anaphylaxis. After MCAo, both LPS and anaphylaxis increased microglial interleukin-1α (IL-1α) expression and blood-brain barrier breakdown. LPS caused marked granulocyte recruitment throughout the ipsilateral hemisphere. To investigate whether reduction of ischaemic damage can improve outcome in systemic inflammation, controlled hypothermia was performed. Hypothermia reduced infarct size in all treatment groups and moderately improved survival, but failed to reduce excess oedema formation after anaphylaxis and LPS-induced neuroinflammation. CONCLUSIONS Our results suggest that systemic inflammatory conditions induce cerebrovascular inflammation via diverse mechanisms. Increased brain inflammation, blood-brain barrier injury and brain oedema formation can be major contributors to impaired outcome in mice after experimental stroke with systemic inflammatory stimuli, independently of infarct size.
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Affiliation(s)
- Adám Dénes
- Laboratory of Molecular Neuroendocrinology, Institute of Experimental Medicine, Budapest, Hungary.
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Wang DZ, Nair DS, Talkad AV. Acute Decompressive Hemicraniectomy to Control High Intracranial Pressure in Patients with Malignant MCA Ischemic Strokes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:225-32. [PMID: 21360089 DOI: 10.1007/s11936-011-0121-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT Malignant middle cerebral artery (MCA) infarction occurs in about 10% of all patients with supratentorial ischemic strokes. The infarction involves the entire MCA territory. Due to the consequences of severe brain edema, brain herniation, elevated intracranial pressure (ICP), and midline shift, these events carry a mortality rate of up to 80%. No clinical trials have been conducted to study the efficacy of the osmotic agents such as mannitol or hypertonic saline. Furthermore, aggressive use of such treatments may be detrimental. Surgical decompression has previously been proposed as a way to relieve the vicious cycle of malignant cerebral edema and reduced cerebral perfusion. Its use in relieving ICP is also controversial. Recently, a pooled analysis of three independent European trials has shown that decompressive hemicraniectomy is clearly beneficial in reducing mortality from large hemispheric infarctions. Although controversies still exist on its indications, surgical decompression can effectively reduce ICP, reduce mortality, and improve neurologic outcomes in selected patients with a malignant MCA stroke syndrome.
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Affiliation(s)
- David Z Wang
- INI Stroke Network, OSF Healthcare System, Department of Neurology, University of Illinois College of Medicine At Peoria, 530 NE Glen Oak Avenue, Peoria, IL, 61637, USA,
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Abstract
Treatment of acute stroke is difficult due to the complexity of events triggered by ischemic insult. Current reperfusion strategies are time limited and, alone, may not be sufficient to achieve maximal neurologic outcomes. Therapeutic hypothermia (TH) appears to be a promising neuroprotective therapy, as it affects a wide range of destructive mechanisms occurring in ischemic brain tissue. Animal research has substantiated the use of TH in acute stroke. Human studies utilizing TH in acute stroke have shown trends toward positive effects; however, there have been a variety of measurements and methods making comparisons difficult. The ideal protocol for the use of TH in stroke has not yet been developed and requires determination of optimal depth, duration, and methods of temperature measurement and cooling for acute stroke. The purposes of this article were to (1) discuss the effects of ischemia and reperfusion in acute stroke, (2) discuss how TH can potentially limit neurological injury, and (3) review current literature on the use of hypothermia as a treatment for acute stroke.
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Jüttler E, Bösel J, Amiri H, Schiller P, Limprecht R, Hacke W, Unterberg A. DESTINY II: DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II. Int J Stroke 2011; 6:79-86. [PMID: 21205246 DOI: 10.1111/j.1747-4949.2010.00544.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with severe space-occupying--so-called malignant--middle cerebral artery infarcts have a poor prognosis even under maximum intensive care treatment. Randomised trials demonstrated that early hemicraniectomy reduces mortality from about 70% to 20% without increasing the risk of being very severely disabled. Hemicraniectomy increases the chance to survive completely independent more than fivefold and doubles the chance to survive at least partly independent. Only patients up to 60-years have been included in these trials. However, patients older than 60-years represent about 50% of all patients with malignant middle cerebral artery infarcts. Data from observational studies, suggesting that older patients may not profit from hemicraniectomy, are inconclusive, because these patients have generally been treated later and less aggressively. This leads to great uncertainty in everyday clinical practice. AIMS To investigate the efficacy of early hemicraniectomy in patients older than 60-years with malignant MCA infarcts. MATERIALS & METHODS DEcompressive Surgery for the Treatment of malignant INfarction of the middle cerebral arterY II is a randomised controlled trial including patients 61-years and older with malignant middle cerebral artery infarcts. Patients are randomised to either maximum conservative treatment alone or in addition to early hemicraniectomy within 48 h after symptom onset. The trial uses a sequential design with a maximum number of 160 patients to be enrolled (ISRCTN 21702227). DISCUSSION In the face of an ageing population, the potential benefit of hemicraniectomy in older patients is of major clinical relevance, but remains controversial. CONCLUSION The results of this trial are expected to directly influence decision making in these patients.
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Affiliation(s)
- Eric Jüttler
- Department of Neurology, University of Heidelberg, Heidelberg, Germany.
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Jüttler E, Hacke W. Cerebral Infarction. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Several case series had suggested decompressive hemicraniectomy as a life-saving therapy, but, until recently, there was no proof for this procedure from randomized controlled trials. RECENT FINDINGS In 2007, results from a pooled analysis of three European trials as well as data from two of these trials were published and yield compelling evidence for the benefit of hemicraniectomy. SUMMARY Data from the published trials leave no doubt about the benefit especially the life-saving character of hemicraniectomy for malignant hemispheric infarction. However, some open questions (i.e. timing of surgery, age limit for hemicraniectomy) remain to be answered in the future.
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Huttner HB, Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009; 8:949-58. [DOI: 10.1016/s1474-4422(09)70224-8] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Huttner HB, Jüttler E, Schwab S. Hemicraniectomy for middle cerebral artery infarction. Curr Neurol Neurosci Rep 2008; 8:526-33. [PMID: 18957191 DOI: 10.1007/s11910-008-0083-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The space-occupying so-called "malignant" middle cerebral artery infarction is-besides acute basilar artery occlusion-the most devastating form of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized controlled trials provided evidence for the benefit of early hemicraniectomy with respect to mortality after 3 months. This review focuses on current treatment options for malignant ischemic brain infarction, especially hemicraniectomy. Moreover, major unsolved problems and open questions regarding the disease are discussed, and perspective is given on future clinical studies.
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Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen, Erlangen, Germany
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Jüttler E, Köhrmann M, Aschoff A, Huttner HB, Hacke W, Schwab S. Hemicraniectomy for space-occupying supratentorial ischemic stroke. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.3.251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Space-occupying, malignant hemispheric infarction is one of the most devastating forms of ischemic stroke. Until recently, there was no proven treatment. In 2007, results from randomized, controlled trials provided evidence for the benefit of early hemicraniectomy. This paper provides an overview on the current treatment options for malignant ischemic brain infarction, with a focus on hemicraniectomy. We also discuss major unsolved problems and open questions regarding the disease. Finally, we give a perspective on future clinical studies in this field of stroke.
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Affiliation(s)
- Eric Jüttler
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Martin Köhrmann
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Alfred Aschoff
- University of Heidelberg, Department of Neurosurgery, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Hagen B Huttner
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
| | - Werner Hacke
- University of Heidelberg, Department of Neurology, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany
| | - Stefan Schwab
- University of Erlangen, Department of Neurology, Schwabachanlage 6, D-91054 Erlangen, Germany
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