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Humayra S, Yahya N, Ning CJ, Raffali MAAFBM, Mir IA, Mohamed AL, Manan HA. Relationship between carotid intima-media thickness and white matter hyperintensities in non-stroke adults: a systematic review. Front Neuroanat 2024; 18:1394766. [PMID: 38903057 PMCID: PMC11188707 DOI: 10.3389/fnana.2024.1394766] [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: 03/02/2024] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Literature suggests a common pathophysiological ground between carotid atherosclerosis (CAS) and white matter alterations in the brain. However, the association between carotid intima-media thickness (CIMT) and white matter hyperintensities (WMH) has not been conclusively reported. The current systematic review explores and reports the relationship between CIMT and WMH among asymptomatic/non-stroke adults. Methods A recent literature search on PubMed, SCOPUS, and Web of Science databases was conducted in compliance with the PRISMA protocol. The pre-defined Population-Intervention-Comparison-Outcome-Study (PICOS) criteria included observational studies investigating the CIMT-WMH association among non-stroke adults undergoing magnetic resonance imaging and carotid ultrasound. Results Out of 255 potential results, 32 studies were critically assessed for selection, and finally, 10 articles were included, comprising 5,116 patients (females = 60.2%; males = 39.8%) aged between 36-71 years. The included studies earned high quality ratings (6-9) based on the Newcastle-Ottawa-Scale criteria. Qualitative synthesis showed a significantly parallel relationship between increased CIMT and greater WMH burden in 50% of the studies. In addition, significant risk factors related to the CIMT-WMH association included older age, hypertension, depression, migraine, Hispanic ethnicity, and apolipoprotein E (ɛ4) in postmenopausal women. Conclusion Overall, the cumulative evidence showed a consistent CIMT-WMH association in asymptomatic middle-aged and older non-stroke adults, indicating that CAS may contribute to the progression of pathologically hyperintense white matter in the brain. However, further research is warranted to infer the plausible relationship between CIMT and WMH in the absence of stroke.
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Affiliation(s)
- Syeda Humayra
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), Department of Radiology, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noorazrul Yahya
- Diagnostic Imaging & Radiotherapy Program, School of Diagnostic & Applied Health Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chai Jia Ning
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), Department of Radiology, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Radiology and Intervention, Hospital Pakar Kanak-Kanak (UKM Specialist Children’s Hospital), Universiti Kebangsaan Malaysia, Malaysia
| | | | - Imtiyaz Ali Mir
- Department of Physiotherapy, M Kandiah Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Kajang, Malaysia
| | | | - Hanani Abdul Manan
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), Department of Radiology, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Radiology and Intervention, Hospital Pakar Kanak-Kanak (UKM Specialist Children’s Hospital), Universiti Kebangsaan Malaysia, Malaysia
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2
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Berisha DE, Rizvi B, Chappel-Farley MG, Tustison N, Taylor L, Dave A, Sattari NS, Chen IY, Lui KK, Janecek JC, Keator D, Neikrug AB, Benca RM, Yassa MA, Mander BA. Cerebrovascular pathology mediates associations between hypoxemia during rapid eye movement sleep and medial temporal lobe structure and function in older adults. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.28.577469. [PMID: 38328085 PMCID: PMC10849660 DOI: 10.1101/2024.01.28.577469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Obstructive sleep apnea (OSA) is common in older adults and is associated with medial temporal lobe (MTL) degeneration and memory decline in aging and Alzheimer's disease (AD). However, the underlying mechanisms linking OSA to MTL degeneration and impaired memory remains unclear. By combining magnetic resonance imaging (MRI) assessments of cerebrovascular pathology and MTL structure with clinical polysomnography and assessment of overnight emotional memory retention in older adults at risk for AD, cerebrovascular pathology in fronto-parietal brain regions was shown to statistically mediate the relationship between OSA-related hypoxemia, particularly during rapid eye movement (REM) sleep, and entorhinal cortical thickness. Reduced entorhinal cortical thickness was, in turn, associated with impaired overnight retention in mnemonic discrimination ability across emotional valences for high similarity lures. These findings identify cerebrovascular pathology as a contributing mechanism linking hypoxemia to MTL degeneration and impaired sleep-dependent memory in older adults.
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Affiliation(s)
- Destiny E. Berisha
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
| | - Batool Rizvi
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
| | - Miranda G. Chappel-Farley
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
| | - Nicholas Tustison
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
| | - Lisa Taylor
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
| | - Abhishek Dave
- Department of Cognitive Sciences, University of California Irvine, Irvine CA, 92697, USA
| | - Negin S. Sattari
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
| | - Ivy Y. Chen
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
| | - Kitty K. Lui
- San Diego State University/University of California San Diego, Joint Doctoral Program in Clinical Psychology, San Diego, CA, 92093, USA
| | - John C. Janecek
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
| | - David Keator
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
| | - Ariel B. Neikrug
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
| | - Ruth M. Benca
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
- Neuroscience Training Program, University of Wisconsin-Madison, Madison, WI, 53706, USA
- Department of Psychiatry, University of Wisconsin-Madison, Madison, 53706, WI, USA
- Department of Psychiatry and Behavioral Medicine, Wake Forest University, Winston-Salem, NC, 27109, USA
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine, Irvine CA, 92697, USA
| | - Michael A. Yassa
- Department of Neurobiology and Behavior, University of California Irvine, Irvine CA, 92697, USA
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine, Irvine CA, 92697, USA
- Department of Neurology, University of California Irvine, Irvine CA, 92697, USA
| | - Bryce A. Mander
- Center for the Neurobiology of Learning and Memory, University of California Irvine, Irvine CA, 92697, USA
- Department of Psychiatry and Human Behavior, University of California Irvine, Irvine CA, 92697, USA
- Department of Cognitive Sciences, University of California Irvine, Irvine CA, 92697, USA
- Institute for Memory Impairments and Neurological Disorders, University of California Irvine, Irvine CA, 92697, USA
- Department of Pathology and Laboratory Medicine, University of California Irvine, Irvine CA, 92697, USA
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Wang X, Wang C, Miao P, Wei Y, Lin L, Li Z, Zhang Y, Cheng J, Ren C. Reduced GABA concentration in patients with white matter hyperintensities. Front Neurosci 2023; 17:1320247. [PMID: 38156270 PMCID: PMC10752961 DOI: 10.3389/fnins.2023.1320247] [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: 10/12/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
To investigate potential alterations of white matter hyperintensities (WMHs) on J-edited MR spectroscopy (MRS) measures of the primary inhibitory neurotransmitter γ-aminobutyric acid (GABA). Twenty-four WMHs patients and 20 healthy controls (HCs) were recruited to undergo magnetic resonance spectroscopy (MRS) scan at 3T from voxels in left centrum semiovale white matter, using the MEGA point resolved spectroscopy (MEGA-PRESS) technique with the MATLAB-based Gannet tool to estimate GABA+ co-edited macromolecule (GABA+) levels and using Tarquin software to estimate levels of glutamate + glutamine (Glx), total N-acetylaspartate (tNAA), total choline (tCho), and total creatine (tCr). Independent t-tests or Mann-Whitney U-tests were used to test group differences between WMHs and HCs. Additionally, WMHs patients were divided into mild and moderate-severe WMHs subgroup according to the Fazekas scale. Analysis of variance (ANOVA) and post-hoc tests were used among WMHs subgroups and HCs. We found there was a significant reduction in GABA+ levels (p = 0.018) in WMHs patients compared with healthy controls. In subgroup analyses, there was also a significant reduction of GABA+ levels in moderate-severe WMHs subgroup (p = 0.037) and mild WMHs subgroup (p = 0.047) when compared to HCs. Besides, the moderate-severe WMHs subgroup had significantly higher levels of tCho compared with healthy controls (p = 0.019). In conclusion, reduced GABA+ levels in WMHs patients and elevated tCho levels in moderate-severe WMHs were observed when compared with HCs. These results demonstrate that abnormalities of the GABAergic system and choline metabolism may contribute to the pathogenesis of WMHs.
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Affiliation(s)
- Xin Wang
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Caihong Wang
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peifang Miao
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Wei
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liangjie Lin
- Clinical and Technical Support, Philips Healthcare, Beijing, China
| | - Zhen Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yong Zhang
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingliang Cheng
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuiping Ren
- Key Laboratory for Functional Magnetic Resonance Imaging and Molecular Imaging of Henan Province, Department of MRI, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Zhao J, Xu F, Xu W, Lv R, Wang J, Yang X. Higher High-Mobility Group Box-1 Levels are Associated with White Matter Lesions in Ischemic Stroke Patients. J Inflamm Res 2023; 16:4441-4449. [PMID: 37842188 PMCID: PMC10572385 DOI: 10.2147/jir.s432109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/27/2023] [Indexed: 10/17/2023] Open
Abstract
Background and Purpose High-mobility group box-1 (HMGB1) is a useful biomarker for disease severity stratification and prognosis prediction. We aim to explore whether the circulating HMGB1 concentrations are associated with the white matter lesions (WMLs) burden in stroke patients. Methods Between 2022 June and December 2022, patients with acute ischemic stroke were prospectively enrolled. HMGB1 levels were measured by an enzyme-linked immunosorbent assay after admission for all patients. The WMLs severity was assessed by the Fazekas scale. We dichotomized patients into those with moderate-severe WMLs (Fazekas score 3-6) versus those with none-mild WMLs (Fazekas score 0-2). Furthermore, based on the severity of periventricular WMLs (PWMLs) and deep WMLs (DWMLs), patients were categorized as none-mild (Fazekas score 0-1) or moderate-severe (Fazekas score 2-3). Results A total of 287 participants (mean age: 64.9 years; 157 male) were analyzed. The median serum HMGB1 levels were 7.3 ng/mL (interquartile, 4.3 ng/mL-12.3 ng/mL). After adjustment for potential confounders, elevated HMGB1 levels were associated with the presence of moderate-severe WMLs (first quartile vs fourth quartile, odds ratio [OR], 4.101; 95% confidence interval [CI], 1.948-8.633; P = 0.001) and moderate-severe PWMLs (first quartile vs fourth quartile, OR, 9.181; 95% CI, 4.078-20.671; P = 0.001). Similar results were found when the HMGB1 levels were analyzed as a continuous variable. Conclusion This study demonstrated that increased HMGB1 levels were associated with the severity of WMLs, mainly in the periventricular region.
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Affiliation(s)
- Jie Zhao
- Department of Geriatrics, Suzhou Ninth People’s Hospital, Soochow University, Suzhou, Jiangsu, 215200, People’s Republic of China
| | - Fang Xu
- Department of Obstetrics and Gynecology, Suzhou Wujiang District Hospital of Traditional Chinese Medicine, Suzhou, Jiangsu, 215200, People’s Republic of China
| | - Wanying Xu
- Department of Geriatrics, Suzhou Ninth People’s Hospital, Soochow University, Suzhou, Jiangsu, 215200, People’s Republic of China
| | - Rong Lv
- Department of Geriatrics, Suzhou Ninth People’s Hospital, Soochow University, Suzhou, Jiangsu, 215200, People’s Republic of China
| | - Juan Wang
- Department of Endocrine, Suzhou Ninth People’s Hospital, Soochow University, Suzhou, Jiangsu, 215200, People’s Republic of China
| | - Xufeng Yang
- Department of Geriatrics, Suzhou Ninth People’s Hospital, Soochow University, Suzhou, Jiangsu, 215200, People’s Republic of China
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5
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Tsivgoulis G, Palaiodimou L, Stefanou MI, Theodorou A, Kõrv J, Nunes AP, Candelaresi P, Dall'Ora E, Sariaslani P, Provinciali L, Conforto AB, Cidrao AADL, Karapanayiotides T, Ahmed N. Predictors of functional outcome after symptomatic intracranial hemorrhage complicating intravenous thrombolysis: results from the SITS-ISTR. Eur J Neurol 2023; 30:3161-3171. [PMID: 37410547 DOI: 10.1111/ene.15968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND PURPOSE Several risk factors of symptomatic intracerebral hemorrhage (SICH) following intravenous thrombolysis for acute ischaemic stroke have been established. However, potential predictors of good functional outcome post-SICH have been less studied. METHODS Patient data registered in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) from 2005 to 2021 were used. Acute ischaemic stroke patients who developed post intravenous thrombolysis SICH according to the SITS Monitoring Study definition were analyzed to identify predictors of functional outcomes. RESULTS A total of 1679 patients with reported SICH were included, out of which only 2.8% achieved good functional outcome (modified Rankin Scale scores of 0-2), whilst 80.9% died at 3 months. Higher baseline National Institutes of Health Stroke Scale (NIHSS) score and 24-h ΔNIHSS score were independently associated with a lower likelihood of achieving both good and excellent functional outcomes at 3 months. Baseline NIHSS and hematoma location (presence of both SICHs, defined as remote and local SICH concurrently; n = 478) were predictors of early mortality within 24 h. Independent predictors of 3-month mortality were age, baseline NIHSS, 24-h ΔNIHSS, admission serum glucose values and hematoma location (both SICHs). Age, baseline NIHSS score, 24-h ΔNIHSS, hyperlipidemia, prior stroke/transient ischaemic attack, antiplatelet treatment, diastolic blood pressure at admission, glucose values on admission and SICH location (both SICHs) were associated with reduced disability at 3 months (≥1-point reduction across all modified Rankin Scale scores). Patients with remote SICH (n = 219) and local SICH (n = 964) had comparable clinical outcomes, both before and after propensity score matching. CONCLUSIONS Symptomatic intracerebral hemorrhage presents an alarmingly high prevalence of adverse clinical outcomes, with no difference in clinical outcomes between remote and local SICH.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria-Ioanna Stefanou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Ana Paiva Nunes
- Stroke Unit, Hospital São José, Lisbon Central University Hospital Center, Lisbon, Portugal
| | | | - Elisa Dall'Ora
- Stroke Unit, Department of Neurology, Bolzano Central Hospital, Bolzano, Italy
| | - Payam Sariaslani
- Department of Neurology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Leandro Provinciali
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Adriana B Conforto
- Divisão de Neurologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | - Theodore Karapanayiotides
- Second Department of Neurology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Christidi F, Tsiptsios D, Sousanidou A, Karamanidis S, Kitmeridou S, Karatzetzou S, Aitsidou S, Tsamakis K, Psatha EA, Karavasilis E, Kokkotis C, Aggelousis N, Vadikolias K. The Clinical Utility of Leukoaraiosis as a Prognostic Indicator in Ischemic Stroke Patients. Neurol Int 2022; 14:952-980. [PMID: 36412698 PMCID: PMC9680211 DOI: 10.3390/neurolint14040076] [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: 10/04/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Stroke constitutes a major cause of functional disability with increasing prevalence among adult individuals. Thus, it is of great importance for both clinicians and stroke survivors to be provided with a timely and accurate prognostication of functional outcome. A great number of biomarkers capable of yielding useful information regarding stroke patients' recovery propensity have been evaluated so far with leukoaraiosis being among them. Literature research of two databases (MEDLINE and Scopus) was conducted to identify all relevant studies published between 1 January 2012 and 25 June 2022 that dealt with the clinical utility of a current leukoaraiosis as a prognostic indicator following stroke. Only full-text articles published in English language were included. Forty-nine articles have been traced and are included in the present review. Our findings highlight the prognostic value of leukoaraiosis in an acute stroke setting. The assessment of leukoaraiosis with visual rating scales in CT/MRI imaging appears to be able to reliably provide important insight into the recovery potential of stroke survivors, thus significantly enhancing stroke management. Yielding additional information regarding both short- and long-term functional outcome, motor recovery capacity, hemorrhagic transformation, as well as early neurological deterioration following stroke, leukoaraiosis may serve as a valuable prognostic marker poststroke. Thus, leukoaraiosis represents a powerful prognostic tool, the clinical implementation of which is expected to significantly facilitate the individualized management of stroke patients.
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Affiliation(s)
- Foteini Christidi
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Dimitrios Tsiptsios
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
- Correspondence:
| | - Anastasia Sousanidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stefanos Karamanidis
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Sofia Kitmeridou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Stella Karatzetzou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Souzana Aitsidou
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Konstantinos Tsamakis
- Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London, London SE5 8AF, UK
| | - Evlampia A. Psatha
- Department of Radiology, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Efstratios Karavasilis
- Medical Physics Laboratory, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Christos Kokkotis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Nikolaos Aggelousis
- Department of Physical Education and Sport Science, Democritus University of Thrace, 69100 Komotini, Greece
| | - Konstantinos Vadikolias
- Neurology Department, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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