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Greige T, Edlow JA. Managing Acute Headache in Pregnant and Postpartum Women. Ann Emerg Med 2024:S0196-0644(24)00138-0. [PMID: 38597849 DOI: 10.1016/j.annemergmed.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Tatiana Greige
- Department of Neurology, Boston Medical Center, Boston, MA.
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Greige T, Bilello LA, Singleton JM, Edlow JA. Acute headache in pregnant and post-partum patients: A clinical review. Am J Emerg Med 2023; 72:16-19. [PMID: 37451065 DOI: 10.1016/j.ajem.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Headaches during pregnancy and the post-partum period may be due to either an exacerbation of a pre-existing neurological presentation, a new pregnancy-related process, or a non-pregnancy related condition. Key physiologic changes during pregnancy and the post-partum period contribute to the vulnerability of this patient population and the increased risk of complications. OBJECTIVE OF THE REVIEW Review causes of headaches in pregnant and post-partum patients as well as neuroimaging techniques performed. DISCUSSION Headaches are a common complaint for pregnant and post-partum patients. For pregnant patients, a range of serious causes must be considered including cerebral venous thrombosis, posterior reversible encephalopathy syndrome and stroke. Primary headaches are responsible for most post-partum headaches, however other causes also include pre-clampsia, cerebral venous thrombosis and post-dural headache. Determining the optimal imaging technique in this vulnerable population remains a challenge given the scarce guidelines. CONCLUSION The greatest difficulty while evaluating pregnant and post-partum patients presenting with an acute headache in an emergency setting is to determine whether the headache is due to a primary disorder such as migraines or is secondary to an underlying, sometimes serious pathology. The following review explores evidenced-based diagnosis of headache in this particular setting.
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Affiliation(s)
- Tatiana Greige
- Boston Medical Center, Department of Neurology, One Boston Medical Center Pl, Boston, MA 02118, United States of America.
| | - Leslie A Bilello
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America.
| | - Jennifer M Singleton
- University of Colorado Health Highlands Ranch Hospital, Department of Emergency Medicine, 1500 Park Central Drive, Highlands Ranch, CO 80129, United States of America.
| | - Jonathan A Edlow
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America.
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Greige T, Edlow JA, Singleton JM, Bilello LA. Corrigendum to "Acute headache in pregnant and post-partum patients: A clinical review" [The American Journal of Emergency 72(2023) 16-19]. Am J Emerg Med 2023; 72:225. [PMID: 37558510 DOI: 10.1016/j.ajem.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
- Tatiana Greige
- Boston Medical Center, Department of Neurology, One Boston Medical Center Pl, Boston, MA 02118, United States of America.
| | - Jonathan A Edlow
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America
| | - Jennifer M Singleton
- University of Colorado Health Highlands Ranch Hospital, Department of Emergency Medicine, 1500 Park Central Drive, Highlands Ranch, CO 80129, United States of America
| | - Leslie A Bilello
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2(nd) Floor, Boston, MA 02115, United States of America
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Horta L, Bakhtyari A, Greige T, Anand P. Challenging Cases in Neurology: Neurologic Complications of COVID-19. Semin Neurol 2022; 42:708-715. [PMID: 36417991 DOI: 10.1055/a-1985-0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Since the first reported cases of pneumonia in December 2019, coronavirus disease 2019 (COVID-19) has rapidly become recognized as a multisystem illness, with known effects on virtually every organ system. In particular, neurologic complications of COVID-19 have been reported since the beginning of the pandemic in both ambulatory patients with mild disease and critically ill patients. Although it remains unclear whether severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has the potential to directly invade the central nervous system, strokes and other neurovascular complications, sequelae of critical illness and metabolic derangements, parainfectious inflammatory disorders, and a poorly understood post-COVID syndrome have all been reported in patients with COVID-19. Here, we describe cases representing a diverse range of neurologic complications in patients infected with COVID-19.
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Affiliation(s)
- Lucas Horta
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Ava Bakhtyari
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Tatiana Greige
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Greige T, Norton C, Foster LD, Yeatts SD, Thornhill A, Griffin J, Wang J, Hrdlicka CM, Selim M. Why Are Women Less Represented in Intracerebral Hemorrhage Trials? Stroke 2021; 52:442-446. [PMID: 33493043 DOI: 10.1161/strokeaha.120.032166] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 AND PURPOSE Fewer women than men tend to be enrolled in clinical trials of intracerebral hemorrhage. It is unclear whether this reflects lower prevalence of intracerebral hemorrhage in women, selection bias, or poor recruitment efforts. We undertook this study to examine differences between men and women in the reasons for exclusion from the iDEF trial (Intracerebral Hemorrhage Deferoxamine). METHODS The screen failure log included 29 different reasons for exclusion. Chi-square statistics were used to evaluate the differences in reasons for exclusion between men and women. RESULTS A total of 38.2% of participants in iDEF were women. Three thousand nine hundred eighty-two women (45.7%) and 4736 men (54.3%) were screen failures (P<0.0001). Similar proportions of women (1.28%) and men (1.73%) were excluded due to inability to obtain consent (P=0.1). Patients or families declined participation in 1.26% of women versus 1.31% of men (P=0.9). More women than men failed screening because of age>80 (22.40% versus 12.61%; adjusted P=0.0007) and preexisting do-not-resuscitate/do-not-intubate (3.69% versus 2.83%; adjusted P=0.067). CONCLUSIONS Lower rates of women enrollment in the iDEF trial may be attributed to older age. Inability to obtain consent or declining participation was similar between women and men, arguing against selection bias. Our findings should be confirmed in other intracerebral hemorrhage trials to determine best strategies to improve women's representation in future trials.
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Affiliation(s)
- Tatiana Greige
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (T.G., C.N., J.W., C.M.H., M.S.)
| | - Casey Norton
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (T.G., C.N., J.W., C.M.H., M.S.)
| | - Lydia D Foster
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y., A.T., J.G.)
| | - Sharon D Yeatts
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y., A.T., J.G.)
| | - Andre Thornhill
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y., A.T., J.G.)
| | - Jessica Griffin
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (L.D.F., S.D.Y., A.T., J.G.)
| | - Jeffrey Wang
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (T.G., C.N., J.W., C.M.H., M.S.)
| | - Courtney M Hrdlicka
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (T.G., C.N., J.W., C.M.H., M.S.)
| | - Magdy Selim
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (T.G., C.N., J.W., C.M.H., M.S.)
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Murthy SB, Cho SM, Gupta A, Shoamanesh A, Navi BB, Avadhani R, Gruber J, Li Y, Greige T, Lioutas VA, Norton C, Zhang C, Mandava P, Iadecola C, Falcone GJ, Sheth KN, Biffi A, Rosand J, Qureshi AI, Goldstein JN, Kidwell C, Awad I, Selim M, Hanley DF, Woo D, Kamel H, Ziai WC. A Pooled Analysis of Diffusion-Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage. JAMA Neurol 2020; 77:1390-1397. [PMID: 32687564 PMCID: PMC7372494 DOI: 10.1001/jamaneurol.2020.2349] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/30/2020] [Indexed: 12/19/2022]
Abstract
Importance The etiology and significance of diffusion-weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. Objective To evaluate which factors are associated with DWI lesions, whether associated factors differ by ICH location, and whether DWI lesions are associated with functional outcomes. Design, Setting, and Participants This analysis pooled individual patient data from 3 randomized clinical trials (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage trial, and Intracerebral Hemorrhage Deferoxamine phase 2 trial) and 1 multicenter prospective study (Ethnic/Racial Variations of Intracerebral Hemorrhage). Patients were enrolled from August 1, 2010, to September 30, 2018. Of the 4782 patients, 1788 who underwent magnetic resonance imaging scans of the brain were included. Data were analyzed from July 1 to December 31, 2019. Main Outcomes and Measures The primary outcome consisted of factors associated with DWI lesions. Secondary outcomes were poor functional outcome, defined as a modified Rankin score (mRS) of 4 to 6, and mortality, both assessed at 3 months. Mixed-effects logistic regression was used to evaluate the association between exposures and outcomes. Subgroup analyses stratified by hematoma location were performed. Results After exclusion of 36 patients with missing data on DWI lesions, 1752 patients were included in the analysis (1019 men [58.2%]; mean [SD] age, 60.8 [13.3] years). Diffusion-weighted imaging lesions occurred in 549 patients (31.3%). In mixed-effects regression models, factors associated with DWI lesions included younger age (odds ratio [OR] per year, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.64; 95% CI, 1.17-2.30), admission systolic blood pressure (OR per 10-mm Hg increase, 1.13; 95% CI, 1.08-1.18), baseline hematoma volume (OR per 10-mL increase, 1.12; 95% CI, 1.02-1.22), cerebral microbleeds (OR, 1.85; 95% CI, 1.39-2.46), and leukoaraiosis (OR, 1.59; 95% CI, 1.67-2.17). Diffusion-weighted imaging lesions were independently associated with poor mRS (OR, 1.50; 95% CI, 1.13-2.00), but not with mortality (OR, 1.11; 95% CI, 0.72-1.71). In subgroup analyses, similar factors were associated with DWI lesions in lobar and deep ICH. Diffusion-weighted imaging lesions were associated with poor mRS in deep but not lobar ICH. Conclusions and Relevance In a large, heterogeneous cohort of prospectively identified patients with ICH, results were consistent with the hypothesis that DWI lesions represent acute sequelae of chronic cerebral small vessel disease, particularly hypertensive vasculopathy. Diffusion-weighted imaging lesions portend a worse prognosis after ICH, mainly deep hemorrhages.
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Affiliation(s)
- Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Ashkan Shoamanesh
- Population Health Research Institute, Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Joshua Gruber
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Yunke Li
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Tatiana Greige
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Casey Norton
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Pitchaiah Mandava
- Stroke Outcomes Laboratory, Department of Neurology, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro Biffi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston
- Hemorrhagic Stroke Research Program, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | | | | | | | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, The Johns Hopkins University, Baltimore, Maryland
| | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Wendy C. Ziai
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bilello LA, Greige T, Singleton JM, Burke RC, Edlow JA. Retrospective Review of Pregnant Patients Presenting for Evaluation of Acute Neurologic Complaints. Ann Emerg Med 2020; 77:210-220. [PMID: 32418678 DOI: 10.1016/j.annemergmed.2020.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/05/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE Data suggest an increase in neurologic-related hospitalizations during pregnancy. It is crucial for health care providers to develop effective strategies to evaluate this young, generally healthy cohort of patients for whom missed neurologic diagnoses can have devastating results. We aim to describe the epidemiology of this high risk patient population by investigating exam findings, imaging studies, and clinical outcomes of pregnant women presenting to the emergency department (ED) with acute neurologic complaints. METHODS We conducted a 7-year retrospective chart review of pregnant patients presenting with neurologic chief complaints to the emergency department of an urban tertiary academic medical center in the northeastern United States. We investigated examination findings, imaging studies, and clinical outcomes. RESULTS Between January 1, 2010, and May 31, 2017, 205 pregnant patients presented to the ED with a neurologic chief complaint. The majority of patients had a normal neurologic examination result. Patients with an abnormal examination result were not more likely to have clinically significant imaging findings. Within our population, 28% underwent imaging, and noncontrast magnetic resonance imaging was the most common modality. Five patients had clinically significant imaging findings. Specifically, 3.3% of patients with abnormal examination result had significant findings and 2.3% of those with a normal examination result had significant findings. A minority of the patients with a visit resulting in discharge (9.8%) returned to the ED within a 7-day period. None required additional neuroimaging. CONCLUSION To our knowledge, our study is unique in that it incorporated all neurologic complaints. Headache was the most common complaint, followed by dizziness and seizures. Most of the headaches were related to first-trimester migraines. There was a high incidence of imaging used in clinical practice even when there was a normal neurologic examination result. A normal examination result does not adequately exclude serious intracranial pathology, and diagnostic vigilance is justified.
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Affiliation(s)
- Leslie A Bilello
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | | | | | - Ryan C Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jonathan A Edlow
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Murthy SB, Cho SM, Gupta A, Shoamanesh A, Avadhani R, Gruber J, Greige T, Lioutas VA, Norton C, Mandava P, Falcone GJ, Sheth KN, Qureshi AI, Goldstein JN, Kidwell C, Selim M, Woo D, Kamel H, Ziai WC, Hanley DF. Abstract 18: Diffusion Weighted Imaging Lesions in Patients With Acute Intracerebral Hemorrhage: A Pooled Analysis of Individual Patient Data From MISTIE-III, ATACH-II, I-DEF, and ERICH. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The etiology and significance of diffusion weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. We evaluated which factors were associated with DWI lesions, whether associated factors differed by ICH location, and whether DWI lesions were associated with functional outcomes.
Methods:
We pooled individual patient data from the MISTIE III trial, the ATACH-II trial, the i-DEF trial, and the ERICH study. We included only patients who underwent protocolized magnetic resonance imaging (MRI) of the brain. A poor functional outcome was defined as a modified Rankin Scale (mRS) score of 4-6 at 3-6 months. We used mixed effects logistic regression with the study database as a random effect.
Results:
Among 1,775 ICH patients, there were 621 (35.6%) lobar, 978 (55.9%) deep, and 148 (8.5%) infratentorial ICHs. Median time to MRI scan was 1.5 days (IQR, 1-4). DWIHLs occurred in 559 (31.5%) patients, with 190 (34.3%) in lobar ICH and 320 (57.8%) in deep ICHs. In mixed effects regression models, factors associated with DWIHLs included younger age factors associated with DWIHLs after acute ICH included younger age (OR, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.59; 95% CI, 1.18-2.16), admission systolic blood pressure (SBP per 10 mm Hg, OR, 1.13; 95% CI, 1.05-1.22), cerebral microbleeds (OR, 1.71, 95% CI, 1.24-2.35), and leukoaraiosis (OR, 1.60; 95% CI, 1.14-2.25). Patients with DWIHLs had higher odds of mRS 4-6 (OR, 1.57; 95% CI, 1.24-1.99) compared to those without, after adjustment for demographics and ICH severity. In subgroup analyses, similar factors influenced DWIHLs in deep ICH. However, in lobar ICH, younger age, admission SBP, and leukoaraiosis were associated with DWIHLs. Presence of DWIHLs was independently associated with poor mRS in deep ICH but not in lobar ICH. There was no relationship between acute BP lowering and DWIHLs, regardless of location.
Conclusions:
In a large, heterogeneous cohort of ICH patients, our results are consistent with the hypothesis that DWIHLs represent the effects of chronic hypertensive vasculopathy and acute blood pressure elevation. Furthermore, DWIHLs portend poor prognosis after ICH, particularly in deep hemorrhages.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Sung-Min Cho
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Ajay Gupta
- Radiology, Weill Cornell Medicine, New York, NY
| | | | | | - Joshua Gruber
- Johns Hopkins Universtiy Sch of Medicine, Baltimore, MD
| | | | | | | | - Pitchaiah Mandava
- Michael E. DeBakey VA Med Cntr/ Baylor College of Medicine, Houston, TX
| | | | | | | | | | | | | | | | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Dept of Neurology, Weill Cornell Medicine, New York, NY
| | - Wendy C Ziai
- Johns Hopkins Univ Sch of Medicine, Baltimore, MD
| | - Daniel F Hanley
- Brain Injury Outcomes Cntr, Johns Hopkins Univ Sch of Medicine, Baltimore, MD
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