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Inamasu J, Akiyama T, Akaji K, Inaba M, Nishimoto M, Kojima A, Terao S, Hayashi T, Mizutani K, Toda M. Aneurysmal subarachnoid hemorrhage occurring during sleep: Clinical characteristics and risk factors. J Stroke Cerebrovasc Dis 2024; 33:107591. [PMID: 38266691 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107591] [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: 11/30/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is known to be triggered by several specific human activities. Sleep, by contrast, has not been considered a triggering activity for aSAH, and clinical characteristics of patients who sustain aSAH during sleep have rarely been reported in the literature. METHODS This is a retrospective analysis on the data acquired through a multicenter aSAH registry. Between January 2019 and December 2021, a total of 732 aSAH patients had been registered into our database. After excluding 109 patients whose activities at aSAH onset had been unidentifiable, the remaining 623 aSAH patients were dichotomized to 59 patients who sustained aSAH during sleep (Sleep group) and 564 patients who sustained aSAH during daytime activities (Awake group). Two-group comparison of demographic variables and multivariate logistic regression analysis were performed to clarify their clinical characteristics and identify potential risk factors. RESULTS The Sleep group exhibited significantly higher frequencies of diabetes (15.5 % vs. 6.4 %, p = 0.01) and antiplatelet use (13.8 % vs. 4.6 %, p=0.004) than the Awake group. Furthermore, multivariate logistic regression analysis showed that diabetes (OR, 3.051; 95 % CI, 1.281-7.268; p = 0.012) and antiplatelet use (OR, 3.640; 95 % CI, 1.422-9.316; p = 0.007) were correlated with aSAH occurring during sleep. There were no significant inter-group differences in the patient outcomes evaluated at discharge. CONCLUSION The current results indicate that risk factors may exist for aSAH occurring during sleep. Further investigations on how comorbidities such as diabetes, antiplatelet use and sleep apnea affect human hemodynamic and hemostatic parameters during sleep is warranted to better understand those relationships.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi, Utsunomiya 321-0974, Japan.
| | - Takenori Akiyama
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Mihara Memorial Hospital, Isesaki, Japan
| | - Makoto Inaba
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Masaaki Nishimoto
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga, Japan
| | - Atsuhiro Kojima
- Department of Neurosurgery, Saitama City Hospital, Saitama, Japan
| | - Satoshi Terao
- Department of Neurosurgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Takuro Hayashi
- Department of Neurosurgery, NHO Tokyo Medical Center, Tokyo, Japan
| | - Katsuhiro Mizutani
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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Jung TY, Lee E, Park M, Lee JY, Hong YS, Cho J, Guallar E, Hong SD, Jung YG, Gu S, Ryoo JW, Joo EY, Yeon JY, Ryu G, Kim HY. Obstructive Sleep Apnea and Its Influence on Intracranial Aneurysm. J Clin Med 2023; 13:144. [PMID: 38202154 PMCID: PMC10780116 DOI: 10.3390/jcm13010144] [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: 11/26/2023] [Revised: 12/21/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is associated with cerebrovascular disease, which can lead to life-threatening outcomes. The purpose of the study was to investigate the relationship between OSAS and comorbid intracranial aneurysms. We retrospectively reviewed 564 patients who underwent a polysomnography and brain magnetic resonance angiography as part of their health checkup. We calculated the prevalence of an intracranial aneurysm and OSAS in patients and measured the size of the intracranial aneurysm if present. The mean patient age was 55.6 ± 8.5 years, and 82.3% of them were men. The prevalence of an intracranial aneurysm in patients with OSAS was 12.1%, which is significantly higher than patients with non-OSAS (5.9%, p = 0.031). Patients with OSAS had a much higher prevalence of intracranial aneurysms, after adjusting all possible confounding factors such as age, sex, smoking status, alcohol drinking, and body mass index (odds ratio: 2.32; 95% confidence interval: 1.07-5.04). Additionally, the OSAS group had noticeably larger aneurysms compared with those of the non-OSAS group (3.2 ± 2.0 mm vs. 2.0 ± 0.4 mm, p = 0.013). We found a significant association between OSAS and intracranial aneurysms. OSAS could be another risk factor for the development of intracranial aneurysms.
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Affiliation(s)
- Tae Young Jung
- Department of Otorhinolaryngology, Maryknoll Hospital, Busan 48972, Republic of Korea
| | - Eunkyu Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
| | - Minhae Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
| | - Jin-Young Lee
- Health Promotion Center, Samsung Medical Center, Seoul 06351, Republic of Korea;
| | - Yun Soo Hong
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul 06355, Republic of Korea;
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
- Department of Digital Healthcare, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Eliseo Guallar
- Department of Epidemiology, Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Science and Technology, Sungkyunkwan University, Seoul 06355, Republic of Korea;
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
| | - Yong Gi Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
| | - Seonhye Gu
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Jae Wook Ryoo
- Department of Radiology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea
| | - Eun-Yeon Joo
- Department of Neurology, Sleep Center, Samsung Medical Center, Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul 06351, Republic of Korea (M.P.); (Y.G.J.)
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Metwaly NAE, Sobh KM, Ahmed MG, Elaziz AESA, Ahmed SI. Assessment of balloon remodeling techniques in endovascular treatment of wide-neck intracranial aneurysms (WN-IAs). Neurol Res 2022; 45:465-471. [PMID: 36534604 DOI: 10.1080/01616412.2022.2158646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To evaluate the clinical, technical, and angiographic results in endovascular management of wide-neck intracranial aneurysms (WN-IAs) using the balloon-remodeling technique. METHODS This study was a prospective, single-center study that was carried out over a period of three years from January 2019 to December 2021 at the Neuro-Interventional Unit at our hospital. Patients who presented with WNIAs and were eligible for endovascular treatment using the balloon-remodeling approach were included in the study. RESULTS We included 37 patients with a mean age of 49.7 ± 12.3 years. About 91.9% of the participants had SAH, 5.4% had unruptured aneurysms, and 2.7% had intracranial hemorrhage. The mean time to treatment was 6.97 ± 7.35 days, the mean aneurysm diameter was 5.7 ± 1.7 mm, and the mean neck diameter was 3.8 ± 1.0 mm. The majority of the patients had a dom-to-neck ratio of less than 2 (89.2%). We have used hyper form balloons in 48.6%, hyper glide in 43.2%, Copernic balloons in 5.4%, and eclipse in 2.7%. According to the Raymond-Roy occlusion classification, 86.5% of the patients had complete obliteration, 10.8% had residual neck, and 2.7% had a residual aneurysm. Almost 91.9% had no complications, 2.7% had ischemia, and 5.4% had mild rupture by wire, treated by 5 min hyperinflation of the balloon till hemorrhage stopped. CONCLUSIONS Balloon-assisted detachable coiling is an important option in the treatment of WN-IAs. We found that this technique allowed safe and efficient treatment of aneurysms when conventional treatment had failed due to WN. Endovascular coiling using the balloon remodeling technique of wide neck showed a high technical success rate and good short-term clinical outcomes. A good selection of patients with WN-IAs treated by endovascular coiling using balloon remodeling technique and a good selection of materials used help in decreasing the complications.
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Affiliation(s)
| | | | - Mahmoud Glal Ahmed
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Salah Ibrahim Ahmed
- Department of Neurology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
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Xu J, Li Q, Xu CY, Mao S, Jin JJ, Gu W, Shi Y, Zou CF, Ye L. Obstructive sleep apnea aggravates neuroinflammation and pyroptosis in early brain injury following subarachnoid hemorrhage via ASC/HIF-1α pathway. Neural Regen Res 2022; 17:2537-2543. [PMID: 35535908 PMCID: PMC9120669 DOI: 10.4103/1673-5374.339000] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/24/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022] Open
Abstract
Obstructive sleep apnea can worsen the prognosis of subarachnoid hemorrhage. However, the underlying mechanism remains unclear. In this study, we established a mouse model of subarachnoid hemorrhage using the endovascular perforation method and exposed the mice to intermittent hypoxia for 8 hours daily for 2 consecutive days to simulate sleep apnea. We found that sleep apnea aggravated brain edema, increased hippocampal neuron apoptosis, and worsened neurological function in this mouse model of subarachnoid hemorrhage. Then, we established an in vitro HT-22 cell model of hemin-induced subarachnoid hemorrhage/intermittent hypoxia and found that the cells died, and lactate dehydrogenase release increased, after 48 hours. We further investigated the underlying mechanism and found that sleep apnea increased the expression of hippocampal neuroinflammatory factors interleukin-1β, interleukin-18, interleukin-6, nuclear factor κB, pyroptosis-related protein caspase-1, pro-caspase-1, and NLRP3, promoted the proliferation of astrocytes, and increased the expression of hypoxia-inducible factor 1α and apoptosis-associated speck-like protein containing a CARD, which are the key proteins in the hypoxia-inducible factor 1α/apoptosis-associated speck-like protein containing a CARD signaling pathway. We also found that knockdown of hypoxia-inducible factor 1α expression in vitro greatly reduced the damage to HY22 cells. These findings suggest that sleep apnea aggravates early brain injury after subarachnoid hemorrhage by aggravating neuroinflammation and pyroptosis, at least in part through the hypoxia-inducible factor 1α/apoptosis-associated speck-like protein containing a CARD signaling pathway.
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Affiliation(s)
- Jun Xu
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Qian Li
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chen-Yu Xu
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shan Mao
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jia-Jia Jin
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Wei Gu
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ying Shi
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chun-Fang Zou
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
- Department of Respiration, Nanjing Yuhua Hospital, Yuhua Branch of Nanjing First Hospital, Nanjing, Jiangsu Province, China
| | - Liang Ye
- Department of Respiration, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
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Zaremba S, Albus L, Hadjiathanasiou A, Vatter H, Wüllner U, Güresir E. Aneurysm size and blood pressure severity in patients with intracranial aneurysms and sleep apnea. J Clin Sleep Med 2022; 18:1539-1545. [PMID: 35088709 PMCID: PMC9163607 DOI: 10.5664/jcsm.9906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea is a risk factor for hypertension. Hypertension is associated with aneurysm formation, growth, and rupture of intracranial aneurysm (IA). Retrospectively, symptoms of obstructive sleep apnea are more prevalent in patients with IAs. Studies investigating the prevalence and effect of objectively measured sleep apnea in these patients are sparse. We report on the baseline data of an ongoing prospective study. We cross-sectionally analyzed whether obstructive sleep apnea was associated with larger IAs and increased need for antihypertensive medications in a population of patients with unruptured IA. METHODS 130 adult (≥ 18 years) patients with unruptured IAs were recruited. Patients with ischemic stroke or intracranial hemorrhage within 3 months prior to screening were excluded. We assessed obstructive sleep apnea by full-night respiratory polygraphy. Aneurysm size and antihypertensive medication-as a surrogate parameter for the severity of hypertension-were compared between patients with and without obstructive sleep apnea (apnea-hypopnea index >5 events/h). Aneurysm growth and rupture rate were retrospectively analyzed. RESULTS 101 patients completed the study protocol. Obstructive sleep apnea was diagnosed in 68.0% (17) of male and 34.2% (26) of female participants and associated with more severe hypertension (1.536 ± 0.2 vs 0.74 ± 0.1 drugs; P = .01) and larger aneurysms (6.9 ± 1.0 vs 3.8 ± 0.5 mm; P = .01). CONCLUSIONS Patients with obstructive sleep apnea had more antihypertensive medication and larger IAs, probably due to accelerated aneurysm growth. Sleep apnea should be considered in patients with IAs. More research is needed to investigate the effects of sleep apnea on IAs and aneurysm outcome. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Incidence and Effects of Sleep Apnea on Intracerebral Aneurysms-IESA Study; URL: https://clinicaltrials.gov/ct2/show/NCT02880059; Identifier: NCT02880059. CITATION Zaremba S, Albus L, Hadjiathanasiou A, Vatter H, Wüllner U, Güresir E. Aneurysm size and blood pressure severity in patients with intracranial aneurysms and sleep apnea. J Clin Sleep Med. 2022;18(6):1539-1545.
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Affiliation(s)
- Sebastian Zaremba
- Department of Neurology, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
- Clinic for Sleep Medicine, ZURZACHCare, Lucerne, Switzerland
| | - Luca Albus
- Department of Neurology, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | | | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ullrich Wüllner
- Department of Neurology, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
- DZNE, German Centre for Neurodegenerative Diseases, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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Sun X, Liu B, Chen Y, Lv L, Ye D, Mao Y. Modifiable risk factors for intracranial aneurysms: Evidence from genetic studies. Int J Stroke 2022; 17:1107-1113. [DOI: 10.1177/17474930211065640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Intracranial aneurysm (IA) is a crucial health concern with limited strategies for prevention and treatment. Aim: To identify potentially modifiable risk factors, such as socioeconomic, behaviors, dietary, and cardiometabolic factors, for IA and its subtypes. Methods: Summary statistics for IA were derived from a genome-wide association study with an overall 79,429 participants. Single nucleotide polymorphisms associated with modifiable risk factors at genome-wide significance ( P = 5 × 10–8) were used as instrumental variables. The inverse-variance-weighted method, weighted-median method, Mendelian randomization (MR)-Egger regression, MR-Pleiotropy RESidual Sum and Outlier, and multivariable MR analyses were performed to evaluate the effect estimates. Results: Genetically predicted educational attainment, insomnia, smoking, and systolic and diastolic blood pressure (SBP and DBP) were significantly associated with the risk of IA. The odds ratios (ORs) were 0.44 (95% confidence interval (CI): 0.37–0.52) for educational attainment, 1.15 (95% CI: 1.08–1.23) for insomnia, 1.56 (95% CI: 1.38–1.75) for smoking initiation, 2.69 (95% CI: 1.77–4.07) for cigarette per day, 2.65 (95% CI: 1.72–4.08) for lifetime smoking, 1.07 (95% CI: 1.06–1.09), and 1.06 (95% CI: 1.04–1.10) for SBP and DBP, respectively. Similar effect estimates were observed for unruptured IAs and aneurysmal subarachnoid hemorrhage. Conclusions: This study provided genetic evidence that several modifiable risk factors, including blood pressure, smoking, educational attainment, and insomnia were associated with the risk of IA.
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Affiliation(s)
- Xiaohui Sun
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Bin Liu
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ying Chen
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Linshuoshuo Lv
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ding Ye
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yingying Mao
- Department of Epidemiology, School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
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Fei W, Jiao W, Feng X, Chen X, Wang Y. Intermittent hypoxia mimicking obstructive sleep apnea aggravates early brain injury following ICH via neuroinflammation and apoptosis. Mol Med Rep 2021; 24:824. [PMID: 34558649 PMCID: PMC8485128 DOI: 10.3892/mmr.2021.12464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH) is a subtype of stroke associated with high mortality and morbidity due to the lack of effective therapy. Obstructive sleep apnea (OSA) has been reported to aggravate early brain injury (EBI) and worsen the overall outcome of patients with ICH. However, the precise role of OSA-mediated neuroinflammation and apoptosis following ICH has not been confirmed. The present study aimed to investigate the neuronal damage induced by OSA and the potential molecular mechanisms by which ICH-induced EBI regulates neural apoptosis in a C57BL/6 mouse ICH model. Mortality, neurological score, brain water content and neuronal death were evaluated by Evans blue extravasation, TUNEL staining, ELISA, analysis of reactive oxygen species/lipid peroxidation and western blotting. The results showed that OSA induction decreased survival rate, neurological score and neuron survival and upregulated the protein expression levels of Caspase-3, Bax, cytokines IL-1β, IL-6 and TNF-α and NF-κB, which indicated that OSA-mediated induction of apoptosis and neuroinflammation aggravated neuronal death following ICH. The molecular mechanism was partly dependent on the activating transcription factor/CHOP pathway. Taken together, the results demonstrated that OSA worsens neurological outcomes in mice and increases neuronal death by enhancing neural apoptosis and neuroinflammation.
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Affiliation(s)
- Wenjing Fei
- Department of Neurology, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Wei Jiao
- Department of Nursing, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Xiaoyan Feng
- Department of Neurosurgery, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Xufeng Chen
- Department of Gastroenterology, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
| | - Yuhai Wang
- Department of Neurology, 904th Hospital of Joint Logistic Support Force of PLA, Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu 214044, P.R. China
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