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Lee IH, Heo J, Lee H, Jeong J, Kim J, Han M, Yoo J, Kim J, Baik M, Park H, Jung JW, Kim YD, Nam HS. Long-term outcomes of patients with embolic stroke of undetermined source according to subtype. Sci Rep 2024; 14:9295. [PMID: 38653743 DOI: 10.1038/s41598-024-58292-4] [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: 10/03/2023] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
The prognosis of patients with embolic stroke of undetermined source (ESUS) may vary according to the underlying cause. Therefore, we aimed to divide ESUS into subtypes and assess the long-term outcomes. Consecutive patients with acute ischemic stroke who underwent a comprehensive workup, including transesophageal echocardiography and prolonged electrocardiography monitoring, were enrolled. We classified ESUS into minor cardioembolic (CE) ESUS, arteriogenic ESUS, two or more causes ESUS, and no cause ESUS. Arteriogenic ESUS was sub-classified into complex aortic plaque (CAP) ESUS and non-stenotic (< 50%) relevant artery plaque (NAP) ESUS. A total of 775 patients were enrolled. During 1286 ± 748 days follow-up, 116 major adverse cardiovascular events (MACE) occurred (4.2 events/100 patient-years). Among the ESUS subtypes, CAP ESUS was associated with the highest MACE frequency (9.7/100 patient-years, p = 0.021). Cox regression analyses showed that CAP ESUS was associated with MACE (hazard ratio 2.466, 95% confidence interval 1.305-4.660) and any stroke recurrence (hazard ratio 2.470, 95% confidence interval, 1.108-5.508). The prognosis of ESUS varies according to the subtype, with CAP ESUS having the worst prognosis. Categorizing ESUS into subtypes could improve patient care and refine clinical trials.
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Affiliation(s)
- Il Hyung Lee
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyungwoo Lee
- Department of Neurology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - JaeWook Jeong
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonho Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Minho Han
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Jinkwon Kim
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Yongin Severance Hospital, Yongin, Republic of Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Wen S, Naqvi TZ. 3-D transesophageal echocardiography aids in assessment of embolic stroke due to aortic atherosclerotic plaque: A case series. Echocardiography 2024; 41:e15799. [PMID: 38516862 DOI: 10.1111/echo.15799] [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: 11/03/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024] Open
Abstract
Atherosclerosis is the most common cause of heart disease and stroke. Plaque thickness ≥4 mm in the ascending aorta or aortic arch is strongly correlated with cerebral embolic events and ischemic stroke. However, despite imaging workup, the cause of embolic stroke remains unidentified in many patients. Transesophageal echocardiography (TEE) is the preferred echocardiographic method for the evaluation of cardiac source of emboli. 2D TEE imaging evaluates aortic root and aortic arch in a single plane or two planes with biplane imaging. However, 2D TEE often fails to detect mobile or complex components in the ascending aorta and aortic arch plaques. The routine availability of 3D TEE in current ultrasound systems may significantly improve the assessment of aortic plaques as a potential embolic source. In this case series, we present four consecutive patients with stroke who underwent TEE by a single cardiologist for possible cardioembolic source. Some of these patients may have been labelled as "cryptogenic stroke" or "embolic stroke of undetermined source" (ESUS) due to the presence of insignificant or nonmobile ascending aortic or aortic arch plaques on 2D TEE imaging. In our four consecutive patients with ESUS who underwent TEE by a single operator, 3D TEE showed complex aortic arch plaques with ulceration with mobile components and established these plaques as the likely source of embolic stroke.
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Affiliation(s)
- Songnan Wen
- Department of Cardiovascular Medicine, Division of Echocardiography, Mayo Clinic, Scottsdale, USA
| | - Tasneem Z Naqvi
- Department of Cardiovascular Medicine, Division of Echocardiography, Mayo Clinic, Scottsdale, USA
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Wu J, Zou Y, Meng X, Fan Z, van der Geest R, Cui F, Li J, Zhang T, Zhang F. Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography associated with the risk of acute ischemic stroke occurrence. Eur Radiol 2023:10.1007/s00330-023-10404-w. [PMID: 38001250 DOI: 10.1007/s00330-023-10404-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES Carotid atherosclerosis plays an essential role in the occurrence of ischemic stroke. This study aimed to investigate whether a larger burden of napkin-ring sign (NRS) plaques on cervicocerebral computed tomography angiography (CTA) increased the risk of acute ischemic stroke (AIS). METHODS This retrospective, single-center, cross-sectional study enrolled patients with NRS plaques identified in the subclavian arteries, brachiocephalic trunk, carotid arterial system, and vertebrobasilar circulation on contrast-enhanced cervicocerebral CTA. Patients were divided into AIS and non-AIS groups based on imaging within 12 h of symptom onset. Univariate and multivariate logistic regression analyses were performed to determine the risk factor of AIS occurrence. RESULTS A total of 202 patients (66.72 years ± 8.97, 157 men) were evaluated. Plaques with NRS in each subject of the AIS group (N = 98) were significantly more prevalent than that in the control group (N = 104) (1.96 ± 1.17 vs 1.41 ± 0.62). In the AIS group, there were substantially more NRS plaques on the ipsilateral side than contralateral side (1.55 ± 0.90 vs. 0.41 ± 0.66). NRS located on the ipsilateral side of the AIS showed an area under the receiver curve (AUC) of 0.86 to identify ischemic stroke. NRS plaque amounts were an independent risk factor for AIS occurrence (odds ratio, 1.86) after adjusting for other factors. CONCLUSIONS Increased incidence of napkin-ring sign plaques on cervicocerebral CTA was positively associated with AIS occurrence, which could aid in detecting asymptomatic atherosclerotic patients at high risk of AIS in routine screening or emergency settings. CLINICAL RELEVANCE STATEMENT Napkin-ring sign plaque provides an important imaging target for estimating acute ischemic stroke risk and identifying high-risk patients in routine screening or emergency settings, so that timely anti-atherosclerotic therapy can be used for prevention. KEY POINTS • This cross-sectional study investigated the association between high-risk carotid artery plaques and acute ischemic stroke. • Increased incidence of napkin-ring sign plaques on cervicocerebral computed tomography angiography is positively associated with acute ischemic stroke occurrence. • Napkin-ring signs help identify risky patients prone to acute ischemic stroke to facilitate prevention.
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Affiliation(s)
- Jingping Wu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Ying Zou
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Xiao Meng
- Department of Nutrition, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Zhaoyang Fan
- Department of Radiology, University of Southern California, Los Angeles, CA, USA
| | - Rob van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fang Cui
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Jianyong Li
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Tengyuan Zhang
- Department of Neurology, Hainan Hospital of PLA General Hospital, Sanya, China
| | - Fan Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
- Department of Radiology, Hainan Hospital of PLA General Hospital, Sanya, China.
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Saldaña-Inda I, Garcés-Antón E, Navasa-Melado JM, Bernal-Lafuente C, Tejada-Meza H. Direct carotid puncture for the endovascular treatment of acute ischaemic stroke associated to aortic arch atheroma. Neurologia 2023; 38:606-607. [PMID: 37802553 DOI: 10.1016/j.nrleng.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 12/18/2022] [Indexed: 10/10/2023] Open
Affiliation(s)
- I Saldaña-Inda
- Stroke Unit - Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - E Garcés-Antón
- Stroke Unit - Department of Neurology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - J M Navasa-Melado
- Interventional Neuroradiology Unit - Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - C Bernal-Lafuente
- Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - H Tejada-Meza
- Stroke Unit - Department of Neurology, Hospital Universitario Miguel Servet, Zaragoza, Spain; Interventional Neuroradiology Unit - Department of Radiology, Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón. Universidad de Zaragoza, Spain
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Grosse GM, Leotescu A, Sieweke JT, Schneppenheim S, Budde U, Ziegler NL, Biber S, Gabriel MM, Ernst J, Schuppner R, Lichtinghagen R, Bavendiek U, Widder J, Weissenborn K. ADAMTS-13 activity in stroke of known and unknown cause: Relation to vascular risk factor burden. Front Neurol 2023; 13:1045478. [PMID: 36703637 PMCID: PMC9871749 DOI: 10.3389/fneur.2022.1045478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Background The identification of the underlying mechanism in ischemic stroke has important implications for secondary prevention. A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS-13) has antithrombotic properties and was repeatedly implicated in the pathophysiology of stroke. In this study, we, therefore, aimed to investigate whether ADAMTS-13 is associated with stroke etiology and the burden of vascular risk factors. Methods We determined ADAMTS-13 activity in two prospectively recruited stroke cohorts in the long-term course after the event. Cohort 1 (n = 88) consisted of patients who suffered a stroke due to embolic stroke of undetermined source (ESUS), cardioembolic stroke due to atrial fibrillation (AF), large-artery atherosclerosis, or small vessel disease. In cohort 2, patients with cryptogenic stroke and patent foramen ovale (PFO) scheduled for PFO closure (n = 38) were enrolled. As measures of vascular risk factor burden, the CHA2DS2VASC score, the Essen Stroke Risk Score (ESRS), and the Risk of Paradoxical Embolism (RoPE) score were calculated, as appropriate. Results ADAMTS-13 activity was lower in patients with AF-related stroke compared to patients with ESUS (p = 0.0227), which was, however, due to confounding by vascular risk factors. ADAMTS-13 activity inversely correlated with the ESRS (r = -0.452, p < 0.001) and CHA2DS2VASC (r = -0.375, p < 0.001) in cohort 1. In accordance with these findings, we found a positive correlation between ADAMTS-13 activity and the RoPE score in cohort 2 (r = 0.413, p = 0.010). Conclusion ADAMTS-13 activity is inversely correlated with the number of vascular risk factors across different stroke etiologies. Further study is warranted to establish ADAMTS-13 as a mediator of cerebrovascular risk.
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Affiliation(s)
- Gerrit M. Grosse
- 1Department of Neurology, Hannover Medical School, Hannover, Germany,*Correspondence: Gerrit M. Grosse ✉
| | - Andrei Leotescu
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | - Ulrich Budde
- 3Medilys Laboratory, Asklepios Klinik Altona, Hamburg, Germany
| | - Nora L. Ziegler
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Saskia Biber
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ramona Schuppner
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 4Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Udo Bavendiek
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany
| | - Julian Widder
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany,5Medizinische Klinik VI, Kardiologie, Angiologie und Internistische Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Karin Weissenborn
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
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Mele F, Scopelliti G, Manini A, Ferrari Aggradi C, Baiardo M, Schiavone M, Viecca M, Ianniello A, Bertora P, Forleo GB, Pantoni L. Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment. J Neurol 2023; 270:377-385. [PMID: 36098839 PMCID: PMC9469058 DOI: 10.1007/s00415-022-11370-x] [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: 07/26/2022] [Revised: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke. METHODS Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as "cardioembolic", "atherosclerotic", or "mixed" based on the detection of AF and NCP/AAA. Patients with "true cryptogenic" stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology. RESULTS Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001). DISCUSSION One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.
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Affiliation(s)
- Francesco Mele
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Giuseppe Scopelliti
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy ,Univ. Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience & Cognition, Lille, France
| | - Arianna Manini
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy ,Department of Pathophysiology and Transplantation, “Dino Ferrari” Center, University of Milan, Milan, Italy
| | - Carola Ferrari Aggradi
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | - Matteo Baiardo
- Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | - Marco Schiavone
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Maurizio Viecca
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | | | - Pierluigi Bertora
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy ,Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
| | | | - Leonardo Pantoni
- Neurology Unit, Luigi Sacco University Hospital, Milan, Italy ,Department of Biomedical and Clinical Sciences, University of Milan, Via Giovanni Battista Grassi, 74, 20157 Milan, Italy
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Shehjar F, Maktabi B, Rahman ZA, Bahader GA, James AW, Naqvi A, Mahajan R, Shah ZA. Stroke: Molecular mechanisms and therapies: Update on recent developments. Neurochem Int 2023; 162:105458. [PMID: 36460240 PMCID: PMC9839659 DOI: 10.1016/j.neuint.2022.105458] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022]
Abstract
Stroke, a neurological disease, is one of the leading causes of death worldwide, resulting in long-term disability in most survivors. Annual stroke costs in the United States alone were estimated at $46 billion recently. Stroke pathophysiology is complex, involving multiple causal factors, among which atherosclerosis, thrombus, and embolus are prevalent. The molecular mechanisms involved in the pathophysiology are essential to understanding targeted drug development. Some common mechanisms are excitotoxicity and calcium overload, oxidative stress, and neuroinflammation. In addition, various modifiable and non-modifiable risk factors increase the chances of stroke manifolds. Once a patient encounters a stroke, complete restoration of motor ability and cognitive skills is often rare. Therefore, shaping therapeutic strategies is paramount for finding a viable therapeutic agent. Apart from tPA, an FDA-approved therapy that is applied in most stroke cases, many other therapeutic strategies have been met with limited success. Stroke therapies often involve a combination of multiple strategies to restore the patient's normal function. Certain drugs like Gamma-aminobutyric receptor agonists (GABA), Glutamate Receptor inhibitors, Sodium, and Calcium channel blockers, and fibrinogen-depleting agents have shown promise in stroke treatment. Recently, a drug, DM199, a recombinant (synthetic) form of a naturally occurring protein called human tissue kallikrein-1 (KLK1), has shown great potential in treating stroke with fewer side effects. Furthermore, DM199 has been found to overcome the limitations presented when using tPA and/or mechanical thrombectomy. Cell-based therapies like Neural Stem Cells, Hematopoietic stem cells (HSCs), and Human umbilical cord blood-derived mesenchymal stem cells (HUCB-MSCs) are also being explored as a treatment of choice for stroke. These therapeutic agents come with merits and demerits, but continuous research and efforts are being made to develop the best therapeutic strategies to minimize the damage post-stroke and restore complete neurological function in stroke patients.
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Affiliation(s)
- Faheem Shehjar
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Briana Maktabi
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Zainab A Rahman
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Ghaith A Bahader
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Antonisamy William James
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Ahmed Naqvi
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Reetika Mahajan
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA
| | - Zahoor A Shah
- Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences, Toledo, OH, USA.
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Sakai Y, Lehman VT, Eisenmenger LB, Obusez EC, Kharal GA, Xiao J, Wang GJ, Fan Z, Cucchiara BL, Song JW. Vessel wall MR imaging of aortic arch, cervical carotid and intracranial arteries in patients with embolic stroke of undetermined source: A narrative review. Front Neurol 2022; 13:968390. [PMID: 35968273 PMCID: PMC9366886 DOI: 10.3389/fneur.2022.968390] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Despite advancements in multi-modal imaging techniques, a substantial portion of ischemic stroke patients today remain without a diagnosed etiology after conventional workup. Based on existing diagnostic criteria, these ischemic stroke patients are subcategorized into having cryptogenic stroke (CS) or embolic stroke of undetermined source (ESUS). There is growing evidence that in these patients, non-cardiogenic embolic sources, in particular non-stenosing atherosclerotic plaque, may have significant contributory roles in their ischemic strokes. Recent advancements in vessel wall MRI (VW-MRI) have enabled imaging of vessel walls beyond the degree of luminal stenosis, and allows further characterization of atherosclerotic plaque components. Using this imaging technique, we are able to identify potential imaging biomarkers of vulnerable atherosclerotic plaques such as intraplaque hemorrhage, lipid rich necrotic core, and thin or ruptured fibrous caps. This review focuses on the existing evidence on the advantages of utilizing VW-MRI in ischemic stroke patients to identify culprit plaques in key anatomical areas, namely the cervical carotid arteries, intracranial arteries, and the aortic arch. For each anatomical area, the literature on potential imaging biomarkers of vulnerable plaques on VW-MRI as well as the VW-MRI literature in ESUS and CS patients are reviewed. Future directions on further elucidating ESUS and CS by the use of VW-MRI as well as exciting emerging techniques are reviewed.
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Affiliation(s)
- Yu Sakai
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Vance T. Lehman
- Department of Radiology, The Mayo Clinic, Rochester, MN, United States
| | - Laura B. Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States
| | | | - G. Abbas Kharal
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland, OH, United States
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Grace J. Wang
- Department of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Brett L. Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jae W. Song
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Jae W. Song
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9
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Fletcher AJ, Tew YY, Tzolos E, Joshi SS, Kaczynski J, Nash J, Debono S, Lembo M, Kwiecinski J, Bing R, Syed MBJ, Doris MK, van Beek EJR, Moss AJ, Jenkins WS, Walker NL, Joshi NV, Pawade TA, Adamson PD, Whiteley WN, Wardlaw JM, Slomka PJ, Williams MC, Newby DE, Dweck MR. Thoracic Aortic 18F-Sodium Fluoride Activity and Ischemic Stroke in Patients With Established Cardiovascular Disease. JACC Cardiovasc Imaging 2022; 15:1274-1288. [PMID: 35183477 PMCID: PMC9252920 DOI: 10.1016/j.jcmg.2021.12.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/24/2021] [Accepted: 12/23/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aortic atherosclerosis represents an important contributor to ischemic stroke risk. Identifying patients with high-risk aortic atheroma could improve preventative treatment strategies for future ischemic stroke. OBJECTIVES The purpose of this study was to investigate whether thoracic 18F-sodium fluoride positron emission tomography (PET) could improve the identification of patients at the highest risk of ischemic stroke. METHODS In a post hoc observational cohort study, we quantified thoracic aortic and coronary 18F-sodium fluoride activity in 461 patients with stable cardiovascular disease undergoing PET combined with computed tomography (CT). Progression of atherosclerosis was assessed by change in aortic and coronary CT calcium volume. Clinical outcomes were determined by the occurrence of ischemic stroke and myocardial infarction. We compared the prognostic utility of 18F-sodium fluoride activity for predicting stroke to clinical risk scores and CT calcium quantification using survival analysis and multivariable Cox regression. RESULTS After 12.7 ± 2.7 months, progression of thoracic aortic calcium volume correlated with baseline thoracic aortic 18F-sodium fluoride activity (n = 140; r = 0.31; P = 0.00016). In 461 patients, 23 (5%) patients experienced an ischemic stroke and 32 (7%) a myocardial infarction after 6.1 ± 2.3 years of follow-up. High thoracic aortic 18F-sodium fluoride activity was strongly associated with ischemic stroke (HR: 10.3 [95% CI: 3.1-34.8]; P = 0.00017), but not myocardial infarction (P = 0.40). Conversely, high coronary 18F-sodium fluoride activity was associated with myocardial infarction (HR: 4.8 [95% CI: 1.9-12.2]; P = 0.00095) but not ischemic stroke (P = 0.39). In a multivariable Cox regression model including imaging and clinical risk factors, thoracic aortic 18F-sodium fluoride activity was the only variable associated with ischemic stroke (HR: 8.19 [95% CI: 2.33-28.7], P = 0.0010). CONCLUSIONS In patients with established cardiovascular disease, thoracic aortic 18F-sodium fluoride activity is associated with the progression of atherosclerosis and future ischemic stroke. Arterial 18F-sodium fluoride activity identifies localized areas of atherosclerotic disease activity that are directly linked to disease progression and downstream regional clinical atherothrombotic events. (DIAMOND-Dual Antiplatelet Therapy to Reduce Myocardial Injury [DIAMOND], NCT02110303; Study Investigating the Effect of Drugs Used to Treat Osteoporosis on the Progression of Calcific Aortic Stenosis [SALTIRE II], NCT02132026; Novel Imaging Approaches To Identify Unstable Coronary Plaques, NCT01749254; and Role of Active Valvular Calcification and Inflammation in Patients With Aortic Stenosis, NCT01358513).
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Affiliation(s)
- Alexander J Fletcher
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Yong Y Tew
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Evangelos Tzolos
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Shruti S Joshi
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jakub Kaczynski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer Nash
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Samuel Debono
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Maria Lembo
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Maaz B J Syed
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mhairi K Doris
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Edwin J R van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Alistair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - William S Jenkins
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Niki L Walker
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Scottish Adult Congenital Cardiology Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom
| | - Nikhil V Joshi
- Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, United Kingdom
| | - Tania A Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - William N Whiteley
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M Wardlaw
- Edinburgh Imaging Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom; Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Piotr J Slomka
- Cedars-Sinai Medical Centre, Department of Imaging (Division of Nuclear Cardiology), Los Angeles, USA
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility, Queens Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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10
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Demal TJ, Sitzmann FW, Bax L, von Kodolitsch Y, Brickwedel J, Konertz J, Gaekel DM, Sadeq AJ, Kölbel T, Vettorazzi E, Reichenspurner H, Detter C. Risk factors for impaired neurological outcome after thoracic aortic surgery. J Thorac Dis 2022; 14:1840-1853. [PMID: 35813705 PMCID: PMC9264055 DOI: 10.21037/jtd-21-1591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/17/2022] [Indexed: 11/06/2022]
Abstract
Background We aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery. Methods Data from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days. Results Thoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin. In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion. Conclusions Identified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.
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Affiliation(s)
- Till J Demal
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Franziska W Sitzmann
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Johanna Konertz
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Daniel M Gaekel
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Ahmed J Sadeq
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
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11
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Association between Low Ankle-Brachial Index and Poor Outcomes in Patients with Embolic Stroke of Undetermined Source. J Clin Med 2022; 11:jcm11113073. [PMID: 35683461 PMCID: PMC9181204 DOI: 10.3390/jcm11113073] [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: 04/19/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023] Open
Abstract
We investigated the association of low ankle-brachial index (ABI < 0.9) with major adverse cardiovascular events (MACE) and all-cause mortality in patients with embolic stroke of undetermined source (ESUS) as well as whether the association differed by ESUS subtype. This retrospective single-center study included ESUS patients who underwent transesophageal echocardiography and ABI during hospitalization. ESUS was classified as ESUS with minor cardioembolic source, arteriogenic embolism, two or more causes, or no cause. Arteriogenic embolism was defined and classified as complex aortic or non-stenotic relevant artery plaque. MACE was defined as stroke recurrence, acute coronary syndrome, hospitalization for heart failure, or death. Overall, 829 patients were included, with a median follow-up of 45.8 months. Of these, 42 (5.1%) and 370 (44.6%) had low ABI and arteriogenic embolism, respectively. ABI < 0.9 was independently associated with MACE (hazard ratio [HR]: 2.038, 95% confidence interval [CI]: 1.093−3.801) and all-cause mortality (HR: 3.608, 95% CI: 1.538−8.465) according to the multivariable Cox regression analysis. Between ESUS subtypes, low ABI was independently associated with MACE (HR: 2.513, 95% CI: 1.257−5.023) and all-cause mortality (HR: 5.681, 95% CI: 2.151−15.008) in arteriogenic embolism patients, especially in those with complex aortic plaque. However, in non-arteriogenic embolism patients, low ABI was not related to MACE and mortality. In ESUS patients, low ABI was linked to MACE and all-cause mortality, especially in those with arteriogenic embolisms from complex aortic plaque.
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12
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From cryptogenic to ESUS: Toward precision medicine? Rev Neurol (Paris) 2022; 178:939-952. [PMID: 35597610 DOI: 10.1016/j.neurol.2022.01.016] [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: 11/09/2021] [Revised: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 11/20/2022]
Abstract
Cryptogenic infarctions are infarctions without a defined cause, despite a complete work-up. They differ from infarctions of undetermined causes, which may involve overlapping causes or an incomplete investigation. It is also different from uncommon heritable and non-heritable causes. The term embolic stroke of undetermined source (ESUS) proposed in 2014 is defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources. The major advantage of this definition compared to cryptogenic definition is the proposition of a specific work-up. In a general population, frequent potential sources of embolism in patients with ESUS have been suggested since a long time and include: patent foramen ovale (PFO), covert atrial fibrillation (AF), complex aortic arch atheroma, large vessel atheroma with stenosis<50%, carotid web, atrial cardiomyopathy, thrombophilia associated with cancer. It took almost 30 years to show, in patients under 60 with a cryptogenic stroke and a PFO, that PFO occlusion was superior to medical treatment alone for recurrent stroke. PFO under 60 is therefore no longer a cryptogenic cause of infarction. The concept of cryptogenic stroke and its refinement in ESUS have been fruitful for the identification of PFO associated as a cause. Covert AF can be detected by different techniques but its risk significance for recurrent stroke might be different from the simple electrocardiographic detection of AF. With the development of direct oral anticoagulants (DOAs), randomized studies in patients with ESUS, were run for stroke prevention but no difference was observed between patients treated by DOA compared to aspirin. These studies showed however the heterogeneity of ESUS patients. Further ESUS classification should be considered as a tool to identify homogeneous groups. We propose to further split the ESUS group into different subgroups: ESU-PFO>60-year-old, ESUS-ATH with stenosis<50%, ESUS-AF (covert AF & atrial cardiomyopathy), ESUS-cancer and others. Precision medicine is the ability to make targeted healthcare decisions based on the specific risks of individual patients. One preliminary stage is therefore to identify homogeneous groups suitable in the future for new therapeutic trials and, at the end, for new specific treatments.
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13
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Aubry P, Hamidouche F, Alqudwa A, Naoum-Nehme A, Maiga B, Camara N, Manchon E, Poulos N. [Cryptogenic stroke management : where are we ?]. Ann Cardiol Angeiol (Paris) 2021; 70:373-379. [PMID: 34742466 DOI: 10.1016/j.ancard.2021.10.006] [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: 09/20/2021] [Accepted: 10/02/2021] [Indexed: 10/19/2022]
Abstract
Cryptogenic stroke is an old definition that designates an ischemic stroke with no identifiable cause. The term of the embolic stroke of undetermined source was then introduced to identify non-lacunar strokes in whom thromboembolism was the likely mechanism. This subgroup of cryptogenic strokes remains heterogeneous with many potential and possibly associated embolic causes. Covert atrial fibrillation is probably less often involved than initially expected, in contrast to intracranial and extracranial atherosclerosis. The cardiologist should be involved in the search of underlying causes of ischemic stroke by helping the neurologist to identify the most likely diagnosis. Further research is necessary to select populations that may benefit from more effective and individualized treatment.
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Affiliation(s)
- P Aubry
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse; Département de cardiologie, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Bichat-Claude-Bernard, 75018 Paris.
| | - F Hamidouche
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Alqudwa
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - A Naoum-Nehme
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - B Maiga
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Camara
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - E Manchon
- Service de neurologie, Centre Hospitalier de Gonesse, 95500 Gonesse
| | - N Poulos
- Service de cardiologie, Centre Hospitalier de Gonesse, 95500 Gonesse
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14
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Suzuki M, Fujimoto S, Tanaka R. Response to "Ischemic Stroke Patients with Non-Valvular Atrial Fibrillation have a Risk for Aortogenic Embolizations". J Atheroscler Thromb 2021; 28:789-790. [PMID: 34039831 PMCID: PMC8265926 DOI: 10.5551/jat.62890-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Masayuki Suzuki
- Division of Neurology, Department of Medicine, Jichi Medical University
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University
| | - Ryota Tanaka
- Division of Neurology, Department of Medicine, Jichi Medical University.,Jichi Medical University Hospital
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