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Paciaroni M, Caso V, Agnelli G, Mosconi MG, Giustozzi M, Seiffge DJ, Engelter ST, Lyrer P, Polymeris AA, Kriemler L, Zietz A, Putaala J, Strbian D, Tomppo L, Michel P, Strambo D, Salerno A, Remillard S, Buehrer M, Bavaud O, Vanacker P, Zuurbier S, Yperzeele L, Loos CMJ, Cappellari M, Emiliani A, Zedde M, Abdul-Rahim A, Dawson J, Cronshaw R, Schirinzi E, Del Sette M, Stretz C, Kala N, Reznik M, Schomer A, Grory BM, Jayaraman M, McTaggart R, Yaghi S, Furie KL, Masotti L, Grifoni E, Toni D, Risitano A, Falcou A, Petraglia L, Lotti EM, Padroni M, Pavolucci L, Lochner P, Silvestrelli G, Ciccone A, Alberti A, Venti M, Traballi L, Urbini C, Kargiotis O, Rocco A, Diomedi M, Marcheselli S, Caliandro P, Zauli A, Reale G, Antonenko K, Rota E, Tassinari T, Saia V, Palmerini F, Aridon P, Arnao V, Monaco S, Cottone S, Baldi A, D'Amore C, Ageno W, Pegoraro S, Ntaios G, Sagris D, Giannopoulos S, Kosmidou M, Ntais E, Romoli M, Pantoni L, Rosa S, Bertora P, Chiti A, Canavero I, Saggese CE, Plocco M, Giorli E, Palaiodimou L, Bakola E, Tsivgoulis G, Bandini F, Gasparro A, Terruso V, Mannino M, Pezzini A, Ornello R, Sacco S, Popovic N, Scoditti U, Genovese A, Denti L, Flomin Y, Mancuso M, Ferrari E, Caselli MC, Ulivi L, Giannini N, De Marchis GM. Recurrent Ischemic Stroke and Bleeding in Patients With Atrial Fibrillation Who Suffered an Acute Stroke While on Treatment With Nonvitamin K Antagonist Oral Anticoagulants: The RENO-EXTEND Study. Stroke 2022; 53:2620-2627. [PMID: 35543133 DOI: 10.1161/strokeaha.121.038239] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. METHODS This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. RESULTS After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA2DS2-VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0-1.3] for each point increase; P=0.05) and hypertension (OR, 2.3 [95% CI, 1.0-5.1]; P=0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0-1.2] for each year increase; P=0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4-14.2]; P=0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4-5.5]; P=0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8-1.7]). CONCLUSIONS Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding.
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Affiliation(s)
- Maurizio Paciaroni
- Neurology, Stroke Unit, IRCCS MultiMedica, Milano, Italy (M. Paciaroni).,Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Valeria Caso
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Giancarlo Agnelli
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Maria Giulia Mosconi
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Michela Giustozzi
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - David Julian Seiffge
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.).,Department of Neurology, Inselspital University Hospital, University of Bern, Switzerland (D.J.S.)
| | - Stefan T Engelter
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
| | - Philippe Lyrer
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
| | - Alexandros A Polymeris
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
| | - Lilian Kriemler
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
| | - Annaelle Zietz
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, L.T.)
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, L.T.)
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Hospital and Neurosciences University of Helsinki, Finland (J.P., D. Strbian, L.T.)
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Suzette Remillard
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Manuela Buehrer
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Odessa Bavaud
- Stroke Center, Neurology Service, Department of Clinical Neuroscience, Lausanne University Hospital, University of Lausanne, Switzerland (P.M., D. Strambo, A. Salerno, S.R., M.B., O.B.)
| | - Peter Vanacker
- NeuroVascular Center, Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Belgium (P.V., S.Z., L.Y., C.M.J.L.).,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium (P.V., S.Z., L.Y., C.M.J.L.).,Groeninge Hospital, Kortrijk, Belgium (P.V.)
| | - Susanna Zuurbier
- NeuroVascular Center, Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Belgium (P.V., S.Z., L.Y., C.M.J.L.).,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium (P.V., S.Z., L.Y., C.M.J.L.)
| | - Laetitia Yperzeele
- NeuroVascular Center, Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Belgium (P.V., S.Z., L.Y., C.M.J.L.).,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium (P.V., S.Z., L.Y., C.M.J.L.)
| | - Caroline M J Loos
- NeuroVascular Center, Stroke Unit Antwerp, Department of Neurology, Antwerp University Hospital, Belgium (P.V., S.Z., L.Y., C.M.J.L.).,Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Belgium (P.V., S.Z., L.Y., C.M.J.L.)
| | - Manuel Cappellari
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy (M.C., A.E.)
| | - Andrea Emiliani
- Stroke Unit, DAI di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Verona, Italy (M.C., A.E.)
| | | | - Azmil Abdul-Rahim
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.-R., J.D., R.C.)
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.-R., J.D., R.C.)
| | - Robert Cronshaw
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.-R., J.D., R.C.)
| | - Erika Schirinzi
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.S., M.D.S.)
| | - Massimo Del Sette
- Struttura Complessa di Neurologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy (E.S., M.D.S.)
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Narendra Kala
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Michael Reznik
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Ashley Schomer
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Brian Mac Grory
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.).,Department of Neurology, Duke University School of Medicine, Durham, NC (B.M.G.)
| | - Mahesh Jayaraman
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Ryan McTaggart
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Karen L Furie
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (C.S., N.K., M. Reznik, A. Schomer, B.M.G., M.J., R.M., S.Y., K.L.F.)
| | - Luca Masotti
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | - Elisa Grifoni
- Internal Medicine, San Giuseppe Hospital, Empoli, Italy (L.M., E. Grifoni)
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T., A. Risitano, L. Petraglia)
| | - Angela Risitano
- Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T., A. Risitano, L. Petraglia)
| | - Anne Falcou
- Stroke Unit, Emergency Department, Policlinico Umberto I, Rome, Italy (A.F.)
| | - Luca Petraglia
- Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T., A. Risitano, L. Petraglia)
| | - Enrico Maria Lotti
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni, L. Pavolucci)
| | - Marina Padroni
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni, L. Pavolucci)
| | - Lucia Pavolucci
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L., M. Padroni, L. Pavolucci)
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University, Medical Center, Homburg, Germany (P. Lochner)
| | - Giorgio Silvestrelli
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone)
| | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Italy (G.S., A. Ciccone)
| | - Andrea Alberti
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Michele Venti
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Laura Traballi
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | - Chiara Urbini
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Italy (M. Paciaroni, V.C., G.A., M.G.M., M.G., A.A., M.V., L.T., C.U.)
| | | | - Alessandro Rocco
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A. Rocco, M.D.)
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy (A. Rocco, M.D.)
| | - Simona Marcheselli
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milano, Italy (S. Marcheselli)
| | - Pietro Caliandro
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (P.C.)
| | - Aurelia Zauli
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy (A. Zauli, G.R.)
| | - Giuseppe Reale
- Department of Geriatrics, Neurosciences and Orthopedics, Università Cattolica del Sacro Cuore, Rome, Italy (A. Zauli, G.R.)
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine (K.A.)
| | - Eugenia Rota
- S.C. Neurologia-Stroke Unit, Novi Ligure/Tortona, ASL Alessandria, Italy (E.R.)
| | - Tiziana Tassinari
- Department of Neurology, Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T., V.S.)
| | - Valentina Saia
- Department of Neurology, Stroke Unit, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T.T., V.S.)
| | | | - Paolo Aridon
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Italy (P.A.)
| | - Valentina Arnao
- Neurologia-Stroke Unit ARNAS Civico, Palermo, Italy (V.A., S. Monaco, S.C.)
| | - Serena Monaco
- Neurologia-Stroke Unit ARNAS Civico, Palermo, Italy (V.A., S. Monaco, S.C.)
| | - Salvatore Cottone
- Neurologia-Stroke Unit ARNAS Civico, Palermo, Italy (V.A., S. Monaco, S.C.)
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Cataldo D'Amore
- Stroke Unit, Ospedale di Portogruaro, Venice, Italy (A.B., C.D.)
| | - Walter Ageno
- Department of Medicine, University of Insubria, Ospedale di Circolo, Varese, Italy (W.A., S.P.)
| | - Samuela Pegoraro
- Department of Medicine, University of Insubria, Ospedale di Circolo, Varese, Italy (W.A., S.P.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., D.S.)
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., D.S.)
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Greece (S.G., M.K., E.N.)
| | - Maria Kosmidou
- Department of Neurology, University of Ioannina School of Medicine, Greece (S.G., M.K., E.N.)
| | - Evangelos Ntais
- Department of Neurology, University of Ioannina School of Medicine, Greece (S.G., M.K., E.N.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli)
| | - Leonardo Pantoni
- L. Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Italy (L. Pantoni, P.B.)
| | - Silvia Rosa
- Neurology Unit, ASST Fatebenefratelli - Sacco, Milan, Italy (S.R.)
| | - Pierluigi Bertora
- L. Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Italy (L. Pantoni, P.B.)
| | - Alberto Chiti
- Neurologia, Ospedale Apuano, Massa Carrara, Italy (A. Chiti)
| | - Isabella Canavero
- Emergency Neurology, IRCCS Casimiro Mondino Foundation, Pavia, Italy (I.C.).,Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta," Milano, Italy (I.C.)
| | - Carlo Emanuele Saggese
- Unità di Terapia Neurovascolare. Ospedale "Fabrizio Spaziani," Frosinone, Italy (C.E.S., M.P.)
| | - Maurizio Plocco
- Unità di Terapia Neurovascolare. Ospedale "Fabrizio Spaziani," Frosinone, Italy (C.E.S., M.P.)
| | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (E. Giorli)
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (L. Palaiodimou, E.B., G.T.)
| | - Eleni Bakola
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (L. Palaiodimou, E.B., G.T.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, National and Kapodistrian University of Athens, School of Medicine, Greece (L. Palaiodimou, E.B., G.T.)
| | - Fabio Bandini
- Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)
| | - Antonio Gasparro
- Neurologia, Ospedali Riuniti, Palermo, Italy (A. Gasparro, V.T., M. Mannino)
| | - Valeria Terruso
- Neurologia, Ospedali Riuniti, Palermo, Italy (A. Gasparro, V.T., M. Mannino)
| | - Marina Mannino
- Neurologia, Ospedali Riuniti, Palermo, Italy (A. Gasparro, V.T., M. Mannino)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A.P.)
| | - Raffaele Ornello
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy (R.O., S.S.)
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy (R.O., S.S.)
| | - Nemanja Popovic
- Clinic of Neurology, Clinical Center of Vòsvodina, University of Novi Sad, Serbia (N.P.)
| | - Umberto Scoditti
- Emergency Department, Stroke Unit, University of Parma, Italy. (U.S., A. Genovese)
| | - Antonio Genovese
- Emergency Department, Stroke Unit, University of Parma, Italy. (U.S., A. Genovese)
| | - Licia Denti
- Dipartimento Geriatrico Riabilitativo, Stroke Unit, University of Parma, Italy. (L.D.)
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit, MC Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.)
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, E.F., M.C.C., L.U., N.G.)
| | - Elena Ferrari
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, E.F., M.C.C., L.U., N.G.)
| | - Maria Chiara Caselli
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, E.F., M.C.C., L.U., N.G.)
| | - Leonardo Ulivi
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, E.F., M.C.C., L.U., N.G.)
| | - Nicola Giannini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M. Mancuso, E.F., M.C.C., L.U., N.G.)
| | - Gian Marco De Marchis
- Department of Neurology, Stroke Center, University Hospital Basel, University of Basel, Switzerland (D.J.S., S.T.E., P. Lyrer, A.A.P., L.K., A. Zietz, G.M.D.M.)
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