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Wang JJ, Katz JM, Sanmartin M, Naidich JJ, Rula E, Sanelli PC. Gender-Based Disparity in Acute Stroke Imaging Utilization and the Impact on Treatment and Outcomes: 2012 to 2021. J Am Coll Radiol 2024; 21:128-140. [PMID: 37586470 PMCID: PMC10840948 DOI: 10.1016/j.jacr.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Prior studies have revealed significant socio-economic disparities in neuro-imaging and treatment utilization for patients with acute ischemic stroke (AIS). In this study, we sought to evaluate whether a sex-based disparity exists in neuro-imaging and to determine its etiology and association with acute treatment and outcomes. MATERIALS AND METHODS This was a retrospective study of consecutive patients with AIS admitted to a comprehensive stroke center between 2012 and 2021. Patient demographic and clinical characteristics, neuro-imaging, acute treatment, and early clinical outcomes were extracted from the electronic medical records. Trend analysis, bivariate analysis of patient characteristics by sex, and multivariable logistic regression analyses were conducted. RESULTS Of the 7,540 AIS episodes registered from 2012 to 2021, 47.9% were female patients. After adjusting for demographic, clinical, and temporal factors, significantly higher utilization of CTA was found for male patients (odds ratio = 1.20 [95% confidence interval 1.07-1.34]), particularly from socio-economically advantaged groups, and in years 2015 and 2019, representing the years endovascular thrombectomy recommendations changed. Despite this, male patients had significantly lower intravenous thrombolysis utilization (odds ratio = 0.83 [95% confidence interval 0.71-0.96]) and similar endovascular thrombectomy rates as female patients. There were no significant sex differences in early clinical outcomes, and no relevant clinical or demographic factors explained the CT angiography utilization disparity. CONCLUSION Despite higher CT angiography utilization in socio-economically advantaged male patients with AIS, likely overutilization due to implicit biases following guideline updates, the rates of acute treatment, and early clinical outcomes were unaffected.
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Affiliation(s)
- Jason J Wang
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York; and Professor and Health Economist, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
| | - Jeffrey M Katz
- Associate Professor of Neurology & Radiology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Chief, Neurovascular Services and Neurology Service Line Director, Neuroendovascular Surgery; Director, Comprehensive Stroke Center and Stroke Unit, North Shore University Hospital; Director, Neuroendovascular Surgery, South Shore University Hospital
| | - Maria Sanmartin
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York; and Assistant Professor and Health Economist, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Jason J Naidich
- Chair, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and Senior Vice President and Chief Innovation Officer, Northwell Health, Hempstead, New York
| | - Elizabeth Rula
- Executive Director, The Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York, and Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Timpone VM, Reid M, Jensen A, Poisson SN, Callen AL, Costa B, Trivedi PS. Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis. AJR Am J Roentgenol 2023; 221:673-686. [PMID: 37255044 DOI: 10.2214/ajr.23.29352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.
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Affiliation(s)
- Vincent M Timpone
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Stanford School of Medicine, Palo Alto, CA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado Hospital, Aurora, CO
| | - Andrew L Callen
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Premal S Trivedi
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
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Vagal A, Sucharew H, Wang LL, Kissela B, Alwell K, Haverbusch M, Woo D, Ferioli S, Mackey J, De Los Rios La Rosa F, Mistry EA, Demel SL, Coleman E, Jasne AS, Walsh K, Khatri P, Slavin S, Star M, Stephens C, Kleindorfer D. Trends in Disparities in Advanced Neuroimaging Utilization in Acute Stroke: A Population-Based Study. Stroke 2023; 54:1001-1008. [PMID: 36972349 DOI: 10.1161/strokeaha.122.040790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 02/01/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Our primary objective was to evaluate if disparities in race, sex, age, and socioeconomic status (SES) exist in utilization of advanced neuroimaging in year 2015 in a population-based study. Our secondary objective was to identify the disparity trends and overall imaging utilization as compared with years 2005 and 2010. METHODS This was a retrospective, population-based study that utilized the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) data. Patients with stroke and transient ischemic attack were identified in the years 2005, 2010, and 2015 in a metropolitan population of 1.3 million. The proportion of imaging use within 2 days of stroke/transient ischemic attack onset or hospital admission date was computed. SES determined by the percentage below the poverty level within a given respondent's US census tract of residence was dichotomized. Multivariable logistic regression was used to determine the odds of advanced neuroimaging use (computed tomography angiogram/magnetic resonance imaging/magnetic resonance angiogram) for age, race, gender, and SES. RESULTS There was a total of 10 526 stroke/transient ischemic attack events in the combined study year periods of 2005, 2010, and 2015. The utilization of advanced imaging progressively increased (48% in 2005, 63% in 2010, and 75% in 2015 [P<0.001]). In the combined study year multivariable model, advanced imaging was associated with age and SES. Younger patients (≤55 years) were more likely to have advanced imaging compared with older patients (adjusted odds ratio, 1.85 [95% CI, 1.62-2.12]; P<0.01), and low SES patients were less likely to have advanced imaging compared with high SES (adjusted odds ratio, 0.83 [95% CI, 0.75-0.93]; P<0.01). A significant interaction was found between age and race. Stratified by age, the adjusted odds of advanced imaging were higher for Black patients compared with White patients among older patients (>55 years; adjusted odds ratio, 1.34 [95% CI, 1.15-1.57]; P<0.01), but no racial differences among the young. CONCLUSIONS Racial, age, and SES-related disparities exist in the utilization of advanced neuroimaging for patients with acute stroke. There was no evidence of a change in trend of these disparities between the study periods.
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Affiliation(s)
- Achala Vagal
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
| | - Heidi Sucharew
- Department of Emergency Medicine (H.S.), University of Cincinnati Medical Center, OH
| | - Lily L Wang
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
| | - Brett Kissela
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Kathleen Alwell
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Mary Haverbusch
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Daniel Woo
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Simona Ferioli
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Jason Mackey
- Indiana University School of Medicine, Indianapolis (J.M.)
| | | | - Eva A Mistry
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Stacie L Demel
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | | | | | - Kyle Walsh
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | - Pooja Khatri
- Department of Neurology (B.K., K.A., M.H., D.W., S.F., E.M., S.D., K.W., P.K.), University of Cincinnati Medical Center, OH
| | | | | | - Cody Stephens
- Department of Radiology (A.V., L.W., C.S.), University of Cincinnati Medical Center, OH
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Timpone VM, Reid M, Jensen A, Poisson SN, Patten L, Costa B, Trivedi PS. Lost to Follow-Up: A Nationwide Analysis of Patients With Transient Ischemic Attack Discharged From Emergency Departments With Incomplete Imaging. J Am Coll Radiol 2022; 19:957-966. [PMID: 35724735 DOI: 10.1016/j.jacr.2022.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Imaging guidelines for transient ischemic attack (TIA) recommend that patients undergo urgent brain and neurovascular imaging within 48 hours of symptom onset. Prior research suggests that most patients with TIA discharged from the emergency department (ED) do not complete recommended TIA imaging workup during their ED encounters. The purpose of this study was to determine the nationwide percentage of patients with TIA discharged from EDs with incomplete imaging workup who complete recommended imaging after discharge. METHODS Patients discharged from EDs with the diagnosis of TIA were identified from the Medicare 5% sample for 2017 and 2018 using International Classification of Diseases, tenth rev, Clinical Modification codes. Imaging performed was identified using Current Procedural Terminology codes. Incomplete imaging workup was defined as a TIA encounter without cross-sectional brain, brain-vascular, and neck-vascular imaging performed within the subsequent 30 days of the initial ED encounter. Patient- and hospital-level factors associated with incomplete TIA imaging were analyzed in a multivariable logistic regression. RESULTS In total, 6,346 consecutive TIA encounters were analyzed; 3,804 patients (59.9%) had complete TIA imaging workup during their ED encounters. Of the 2,542 patients discharged from EDs with incomplete imaging, 761 (29.9%) completed imaging during the subsequent 30 days after ED discharge. Among patients with TIA imaging workup completed after ED discharge, the median time to completion was 5 days. For patients discharged from EDs with incomplete imaging, the odds of incomplete TIA imaging at 30 days after discharge were highest for black (odds ratio, 1.84; 95% confidence interval, 1.27-2.66) and older (≥85 years of age; odds ratio, 2.41; 95% confidence interval, 1.78-3.26) patients. Reference values were age cohort 65 to 69 years; male gender; white race; no co-occurring diagnoses of hypertension, hyperlipidemia, or diabetes mellitus; household income > $63,029; hospital in the Northeast region; urban hospital location; hospital size > 400 beds; academically affiliated hospital; and facility with access to MRI. CONCLUSIONS Most patients discharged from EDs with incomplete TIA imaging workup do not complete recommended imaging within 30 days after discharge.
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Affiliation(s)
- Vincent M Timpone
- Director, Stroke and Vascular Imaging and Co-Director, Neuroradiology, Spine Intervention Service, Department of Radiology, University of Colorado Hospital, Aurora, Colorado.
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colorado
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Sharon N Poisson
- Director, Vascular and Stroke Research Fellowship, Department of Neurology, University of Colorado Hospital, Aurora, Colorado
| | - Luke Patten
- Department of Biostatistics & Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Premal S Trivedi
- Director, Health Services Research, Department of Radiology, University of Colorado Hospital, Aurora, Colorado
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Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center. J Am Coll Radiol 2022; 19:348-358. [PMID: 35152960 PMCID: PMC8867840 DOI: 10.1016/j.jacr.2021.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Prior studies have shown socioeconomic disparities in advanced neuroimaging and acute treatment utilization in patients with ischemic stroke. The authors analyzed whether socioeconomic factors were associated with stroke neuroimaging and acute treatment utilization at a comprehensive stroke center. METHODS A retrospective study of consecutive acute ischemic stroke discharges from 2012 to 2020 at a comprehensive stroke center was performed. Differences in neuroimaging (CT angiography [CTA], CT perfusion, MRI, and MR angiography [MRA]) and acute treatment (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]) utilization were evaluated on the basis of socioeconomic factors of age, sex, race, insurance type, and neighborhood-level median household income. Chi-square tests were used for bivariate analyses. Multivariable logistic regression analyses were performed to determine associations between socioeconomic factors and neuroimaging or treatment utilization while controlling for stroke-specific factors and comorbidities. RESULTS Among 6,140 ischemic stroke discharges, race and insurance type were not significantly associated with lower utilization of neuroimaging (CTA, CT perfusion, MRI, and MRA) or acute stroke treatment (IVT and EVT) after controlling for stroke-specific factors and comorbidities. However, median household income < $80,000/year was associated with lower IVT use (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.63-0.87). In addition, age ≥ 80 years had lower CTA (OR, 0.62; 95% CI, 0.51-0.75) and EVT (OR, 0.53; 95% CI, 0.39-0.73) utilization, and female sex had lower CTA (OR, 0.78; 95% CI, 0.65-0.93) utilization. Significantly higher utilization was observed for MRI in Asian (OR, 1.33; 95% CI, 1.04-1.69) and uninsured (OR, 1.64; 95% CI, 1.07-2.50) patients and for MRA (OR, 1.24; 95% CI, 1.04-1.49) and EVT (OR, 1.62; 95% CI, 1.20-2.20) in privately insured patients. CONCLUSIONS Once access to a comprehensive stroke center is achieved, socioeconomic disparities in the utilization of health care resources, particularly advanced neuroimaging and acute treatment, may be improved in patients with ischemic stroke.
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Redundant Imaging in Transient Ischemic Attack: Evidence From the Nationwide Emergency Department Sample. J Am Coll Radiol 2021; 18:1525-1531. [PMID: 34329612 DOI: 10.1016/j.jacr.2021.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/22/2021] [Accepted: 07/01/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Increasing emergency department (ED) compliance with transient ischemic attack (TIA) imaging guidelines has previously been demonstrated, along with a substantial rise in imaging utilization over the past decade. The purpose of this study was to characterize the most commonly used combinations of imaging studies during ED workup of TIA and to quantify prevalence of redundant imaging (RI). METHODS TIA discharges from EDs in the United States from 2006 to 2017 were identified in the Nationwide Emergency Department Sample. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. RI was defined as an ED encounter with any duplicate cross-sectional brain, brain-vascular, or neck-vascular imaging. Patient demographics and hospital characteristics were incorporated into a multivariable logistic regression analysis to identify significant associations with RI. RESULTS There were 184,870 discharges with TIA from EDs in 2017. RI (brain) was observed in 55,513 (30%) of encounters. RI (brain-vascular) and RI (neck-vascular) imaging was identified in 5,149 (2.8%) and 1,325 (0.7%) of encounters, respectively. Decreased odds of obtaining RI was observed in Medicaid patients(odds ratio [OR: 0.72, 95% confidence interval [CI]: 0.64-0.81), non-trauma centers(OR: 0.49, 95% CI: 0.26-0.93), rural hospital locations(OR: 0.18, 95% CI: 0.11-0.29), and weekend encounters(OR: 0.9, 95% CI: 0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in RI (brain) from 2.3% of encounters in 2006 to 30% of encounters in 2017. RI for patients discharged from EDs with TIA in 2017 resulted in additional charges of approximately US $8,670,832. CONCLUSION Increased imaging utilization for TIA workup across EDs in the United States is associated with rising use of redundant imaging. We identify imaging practices that could be targeted to mitigate health care expenditures, while adhering to TIA imaging guidelines.
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Peng JW, Liu Y, Meng G, Zhang JY, Yu LF. Effects of salvianolic acid on cerebral perfusion in patients after acute stroke: A single-center randomized controlled trial. Exp Ther Med 2018; 16:2600-2614. [PMID: 30186492 DOI: 10.3892/etm.2018.6444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/02/2018] [Indexed: 01/01/2023] Open
Abstract
Hypoperfusion following acute stroke is common in the infarct core and periphery tissues. The present study evaluated the efficacy of salvianolic acid (SA) on the cerebral perfusion of patients who had suffered from acute stroke using perfusion-weighted magnetic resonance imaging (PWI) to examine the blood perfusion of the affected brain tissue prior to and following treatment. Patients who were admitted to PLA 153 Central Hospital within 72 h of acute stroke symptom onset and had a Glasgow coma scale ≥5 were randomized into two groups: SA and control groups. Patients in the SA group were administered SA 0.13 g/day for 14 days. PWI was performed for all patients at admission and post-treatment. The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were applied to assess neurological function at admission and 3 months post treatment. A total of 159 patients were enrolled (85 patients in the SA group and 74 patients in the control group). A total of 62 patients in the SA group and 51 patients in the control group exhibited hypoperfusion in the ipsihemisphere of the diffusion-weighted magnetic resonance imaging (DWI) lesion. In addition, relative cerebral blood volume (rCBV), a ratio of the signal value of the region of interest in the same hemisphere of the DWI lesion to that of its mirror in the PWI CBV map, decreased significantly following treatment with SA compared with the control group in patients with hypoperfusion (P=0.02), which were indicated by PWI images at admission, in the DWI lesions or the surrounding areas. Additionally, there was no significant difference in patients with normal perfusion at admission in rCBV in DWI lesions or its surrounding area between the two groups at day 15. However, a significant improvement in NIHSS (P=0.001) and mRS (P=0.005) was indicated in the SA group compared with the control at day 90. The present study indicated that SA may improve the neurological dysfunction of patients with acute stroke, which may be explained by the increased perfusion of hypoperfused brain tissues.
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Affiliation(s)
- Jian-Wei Peng
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Yuan Liu
- Postgraduate Department, Xinxiang Medical College, Xinxiang, Henan 453003, P.R. China
| | - Gai Meng
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Jin-Yan Zhang
- Department of Neurology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
| | - Lian-Fang Yu
- Department of Radiology, People's Liberation Army 153 Central Hospital, Zhengzhou, Henan 450041, P.R. China
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Memon A, McCullough LD. Cerebral Circulation in Men and Women. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:279-290. [DOI: 10.1007/978-3-319-77932-4_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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