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Gili S, Calligaris G, Teruzzi G, Santagostino Baldi G, Muratori M, Montorsi P, Trabattoni D. Patent Foramen Ovale Occlusion in Elderly Patients: Is It Worth It? A Large, Single-Center Retrospective Analysis. J Clin Med 2024; 13:3514. [PMID: 38930044 PMCID: PMC11204738 DOI: 10.3390/jcm13123514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/09/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Patent foramen ovale (PFO) is often diagnosed in patients with cryptogenic stroke, aged > 60-65 years, but few data report the outcomes of PFO closure in elderly patients. Methods: Consecutive patients undergoing PFO closure at a single institution between January 2006 and December 2011 were included. Baseline clinical features and cerebral imaging data were collected, and a RoPE score was calculated for each patient. Procedural data were recorded as well as medical therapy upon discharge. All-cause death, ischemic stroke, TIA and systemic embolism recurrence at long-term follow-up were investigated, as well as new atrial fibrillation onset. Results: Overall, 462 patients were included, of whom 64 (13.8%) were aged ≥ 65 years. Female gender was slightly more prevalent in the younger group while hypertension was more frequent among elderly patients. Previous stroke/TIA was the indication for PFO closure in 95.3% of older patients and 80.4% of younger patients, whereas other indications were more frequent among younger patients. RoPE scores were lower in older patients (median RoPE score of 5 vs. 7), and atrial septal aneurysm was more frequently detected among elderly patients. All procedures were technically successful. Procedural or in-hospital complications equally occurred in 5 (7.8%) older patients (4 AF and 1 device embolization) and 30 (7.5%) young patients (29 AF or other supraventricular arrhythmias and 1 device embolization). The follow-up duration was longer among younger patients. All-cause mortality was higher in older patients (16 deaths vs. 4 at follow-up, log-rank p < 0.001), no recurrent strokes occurred, and 2 TIAs were reported among non-elderly patients. New-onset atrial fibrillation occurred in three elderly and eight young patients. Conclusions: PFO closure is a safe procedure in patients aged ≥ 65 years, associated with favorable long-term follow-up and the prevention of ischemic neurologic recurrences.
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Affiliation(s)
- Sebastiano Gili
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | - Giovanni Teruzzi
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | - Manuela Muratori
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Piero Montorsi
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy
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Apostolos A, Alexiou P, Papanikolaou A, Trantalis G, Drakopoulou M, Ktenopoulos N, Kachrimanidis I, Vlachakis PK, Tsakiri I, Chrysostomidis G, Aggeli K, Tsioufis C, Toutouzas K. Patent Foramen Ovale Closure in Special Clinical Situations: More Questions Than Answers? Life (Basel) 2024; 14:706. [PMID: 38929689 PMCID: PMC11204715 DOI: 10.3390/life14060706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Patent foramen ovale (PFO) is a remnant of the foetal circulation resulting from incomplete occlusion of the septum primum and septum secundum. Although prevalent in about 25% of the population, it mainly remains asymptomatic. However, its clinical significance in situations such as cryptogenic stroke, migraine, and decompression illness (DCI) has been well described. Recent randomised clinical trials (RCTs) have demonstrated the efficacy of percutaneous PFO closure over pharmacological therapy alone for secondary stroke prevention in carefully selected patients. Notably, these trials have excluded older patients or those with concurrent thrombophilia. Furthermore, the role of closure in other clinical conditions associated with PFO, like decompression sickness (DCS) and migraines, remains under investigation. Our review aims to summarise the existing literature regarding epidemiology, pathophysiological mechanisms, optimal management, and closure indications for these special patient groups.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Polyxeni Alexiou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Amalia Papanikolaou
- Department of Cardiology and Angiology, Universitatklinikum Essen, 451 47 Essen, Germany;
| | - Georgios Trantalis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Maria Drakopoulou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Ioannis Kachrimanidis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Panayotis K. Vlachakis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Ismini Tsakiri
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Grigorios Chrysostomidis
- Second Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Konstantina Aggeli
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Costas Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
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Zhang ZQ, Ding JW. Where the cerebral infarction meets child, be vigilant about patent foramen ovale: a case report. Front Neurol 2024; 15:1363867. [PMID: 38827577 PMCID: PMC11140065 DOI: 10.3389/fneur.2024.1363867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Background While cerebral infarction in children is rare, its prognosis is poor, and this condition can seriously burden society and families. A correlation between patent foramen ovale (PFO) and ischemic stroke has not been found in pediatric patients. Case presentation We report a 7-year-old boy who suffered from multiple cerebral infarctions. Subsequently, the patient was diagnosed with an abnormal shunt of PFO. He underwent PFO closure and was followed up for 1 year. The patient did not experience any further cerebral infarction. Conclusions With this case report, we want to illustrate that although the incidence rate of ischemic cerebral infarction in adolescents is very low, we should not neglect the role of PFO. Therefore, after exclusion other causes of cerebral infarction, PFO should be considered in adolescent and adult stroke patients with adult closure criteria in the same way.
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Affiliation(s)
- Zai-qiang Zhang
- Department of Cardiology, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Diseases, China Three Gorges University, Yichang, Hubei, China
| | - Jia-wang Ding
- Department of Cardiology, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei, China
- Institute of Cardiovascular Diseases, China Three Gorges University, Yichang, Hubei, China
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Sverdlichenko I, Donaldson L, Margolin E. Yield of Investigations in Young Patients Presenting With Transient Monocular Vision Loss: A Prospective Study. Am J Ophthalmol 2024; 257:137-142. [PMID: 37690500 DOI: 10.1016/j.ajo.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE It is unclear whether transient monocular vision loss (TMVL) warrants the same thorough systemic evaluation for potential embolic sources in young adults as it does in older adults. The objective of the present study was to evaluate the yield of investigations in patients under 45 years of age presenting with TMVL. DESIGN Prospective cohort study. METHODS Young adult patients with TMVL presenting to a university-affiliated neuro-ophthalmology clinic were included. All included patients were referred for neuroimaging (computed tomography or magnetic resonance angiography of entire carotid tree and magnetic resonance imaging of the brain) and cardiac investigations (transesophageal echocardiography and 2 weeks of Holter monitoring). RESULTS A total of 20 participants with TMVL were included in the study. The mean age was 33.1 ± 8.2 years, and 16 of the 20 participants were women. The most common finding on past medical history was migraines, in 5 of 20 cases (25%), and 25% of patients had headaches during their visual loss. Of 17 participants who completed neuroimaging, 1 had fibromuscular dysplasia (this patient also experienced headaches during their symptoms). Two of 13 patients who completed echocardiography had patent foramen ovale. Overall, 3 of 20 participants (15%, 95% CI 3%-38%) had abnormal findings associated with their TMVL. Aspirin treatment was initiated in 2 of 3 patients following investigations. CONCLUSION In our cohort of young patients presenting with TMVL, 15% of patients had abnormal findings on further investigations. We recommend that young patients presenting with TMVL be referred for neuroimaging and cardiac workup so that appropriate treatments can be initiated to prevent future complications. Headaches during vision loss may not always indicate a benign cause, and retinal migraine should be a diagnosis of exclusion.
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Affiliation(s)
- Irina Sverdlichenko
- From the Faculty of Medicine (I.S.), University of Toronto, Toronto, Ontario, Canada
| | - Laura Donaldson
- Department of Surgery (L.D.), Division of Ophthalmology, McMaster University, Hamilton, Ontario, Canada
| | - Edward Margolin
- Department of Ophthalmology and Vision Sciences (E.M.), University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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Farjat-Pasos JI, Chamorro A, Lanthier S, Robichaud M, Mengi S, Houde C, Rodés-Cabau J. Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives. J Stroke 2023; 25:338-349. [PMID: 37813671 PMCID: PMC10574307 DOI: 10.5853/jos.2023.01599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 10/11/2023] Open
Abstract
Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.
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Affiliation(s)
- Julio I. Farjat-Pasos
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Angel Chamorro
- Department of Neuroscience, Hospital Clinic, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sylvain Lanthier
- Neurovascular Program and Research Center, Montreal Sacre Coeur Hospital; Montreal, Canada
| | - Mathieu Robichaud
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Siddhartha Mengi
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Christine Houde
- Department of Pediatric Cardiology, Laval University Hospital Center, Quebec City, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
- Department of Research & Innovation, Clínic Barcelona, Barcelona, Spain
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Scheitz JF, Sposato LA, Schulz-Menger J, Nolte CH, Backs J, Endres M. Stroke-Heart Syndrome: Recent Advances and Challenges. J Am Heart Assoc 2022; 11:e026528. [PMID: 36056731 PMCID: PMC9496419 DOI: 10.1161/jaha.122.026528] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
After ischemic stroke, there is a significant burden of cardiovascular complications, both in the acute and chronic phase. Severe adverse cardiac events occur in 10% to 20% of patients within the first few days after stroke and comprise a continuum of cardiac changes ranging from acute myocardial injury and coronary syndromes to heart failure or arrhythmia. Recently, the term stroke–heart syndrome was introduced to provide an integrated conceptual framework that summarizes neurocardiogenic mechanisms that lead to these cardiac events after stroke. New findings from experimental and clinical studies have further refined our understanding of the clinical manifestations, pathophysiology, and potential long‐term consequences of the stroke–heart syndrome. Local cerebral and systemic mediators, which mainly involve autonomic dysfunction and increased inflammation, may lead to altered cardiomyocyte metabolism, dysregulation of (tissue‐resident) leukocyte populations, and (micro‐) vascular changes. However, at the individual patient level, it remains challenging to differentiate between comorbid cardiovascular conditions and stroke‐induced heart injury. Therefore, further research activities led by joint teams of basic and clinical researchers with backgrounds in both cardiology and neurology are needed to identify the most relevant therapeutic targets that can be tested in clinical trials.
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Affiliation(s)
- Jan F Scheitz
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,World Stroke Organization Brain & Heart Task Force
| | - Luciano A Sposato
- World Stroke Organization Brain & Heart Task Force.,Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry Western University London Ontario Canada.,Heart & Brain Laboratory Western University London Ontario Canada
| | - Jeanette Schulz-Menger
- Working Group on Cardiovascular Magnetic Resonance, Experimental and Clinical Research Center, a Joint Cooperation Between the Charité-Universitätsmedizin Berlin, Department of Internal Medicine and Cardiology and the Max-Delbrueck Center for Molecular Medicine DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Department of Cardiology and Nephrology HELIOS Klinikum Berlin Buch Berlin Germany
| | - Christian H Nolte
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany
| | - Johannes Backs
- Institute of Experimental Cardiology Heidelberg University Heidelberg Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim Heidelberg Germany
| | - Matthias Endres
- Department of Neurology With Experimental Neurology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Stroke Research Berlin Charité-Universitätsmedizin Berlin Berlin Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin Berlin Germany.,Berlin Institute of Health (BIH) Berlin Germany.,DZNE (German Center for Neurodegenerative Disease), Partner Site Berlin Berlin Germany.,ExcellenceCluster NeuroCure Berlin Germany
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Huber C, Wachter R, Pelz J, Michalski D. Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review. Front Neurol 2022; 13:855656. [PMID: 35572930 PMCID: PMC9103873 DOI: 10.3389/fneur.2022.855656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.
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Affiliation(s)
- Charlotte Huber
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Leipzig, Germany
- *Correspondence: Dominik Michalski
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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