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Roemer SN, Friedrich EB, Kettner M, Rauzi M, Schub P, Kulikovski J, Janitschke D, Stögbauer J, Lochner P. Transorbital sonography and MRI reliability to assess optic nerve sheath diameter in idiopathic intracranial hypertension. J Neuroimaging 2023; 33:375-380. [PMID: 36859645 DOI: 10.1111/jon.13092] [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] [Received: 12/21/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate the performance of magnetic resonance imaging (MRI) in measuring the optic nerve sheath diameter (ONSD) compared to the established method transorbital sonography (TOS) in patients with idiopathic intracranial hypertension (IIH). METHODS Twenty-three patients with IIH were prospectively included applying IIH diagnostic criteria. All patients received a lumbar puncture with assessment of the cerebrospinal fluid (CSF) opening pressure to assure the IIH diagnosis. Measurement of ONSD was performed 3 mm posterior to inner sclera surface in B-TOS by an expert examiner, while three independent neuroradiologists took measurements in axial T-weighted MRI examinations. The sella turcica with the pituitary gland (and potential presence of an empty sella) and the trigeminal cavity were also assessed on sagittal and transversal T1-weighted MRI images by one independent neuroradiologist. RESULTS The means of ONSD between ultrasound and MRI measurements were 6.3 mm (standard deviation [SD] = 0.6 mm) and 6.2 mm (SD = 0.8 mm). The interrater reliability between three neuroradiologists showed a high interclass correlation coefficient (ICC) (confidence interval: .573 < ICC < .8; p < .001). In patients with an empty sella, the ONSD evaluated by MRI was 6.6 mm, while measuring 6.1 mm in patients without empty sella. No correlation between CSF opening pressure and ONSD was found. CONCLUSIONS MRI can reliably measure ONSD and yields similar results compared to TOS in patients with IIH. Moreover, patients with empty sella showed significantly larger ONSD than patients without empty sella.
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Affiliation(s)
- Sebastian Niclas Roemer
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | | | - Michael Kettner
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Martina Rauzi
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Peter Schub
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Daniel Janitschke
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Jakob Stögbauer
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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2
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Simgen A, Roth C, Kulikovski J, Papanagiotou P, Roumia S, Dietrich P, Mühl-Benninghaus R, Kettner M, Reith W, Yilmaz U. Endovascular treatment of unruptured intracranial aneurysms with flow diverters: A retrospective long-term single center analysis. Neuroradiol J 2023; 36:76-85. [PMID: 35695038 PMCID: PMC9893170 DOI: 10.1177/19714009221108678] [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] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The introduction of flow diverters (FDs) in 2007 greatly enhanced the treatment of intracranial aneurysms. Here, we present our long-term clinical experience in treating unruptured intracranial aneurysms with FDs. METHODS 107 patients with unruptured aneurysms and treated with an FD between 2010 and 2019 were retrospectively reviewed. Aneurysm occlusion, procedural complications, and clinical outcome were evaluated. RESULTS Angiographic follow-up was available for 93 patients with a mean long-term follow-up time of 28.4 ± 21.6 months. Additional coiling was performed in 15.1% of patients (n = 14). Adequate aneurysm occlusion (Kamran grades 3 and 4) at long-term follow-up was achieved in 94.6% of patients (n = 88). 3.2% (n = 3) required endovascular retreatment since the last follow-up showed a lack of aneurysm occlusion (Kamran grade 0) due to a foreshortening of the FD. Incomplete opening of the FD and parent vessel occlusion was seen in 1.1% (n = 1) and 3.2% (n = 3) of patients, respectively. In-stent stenosis was observed in 57% (n = 53) of cases at short-term follow-up and 22.6% (n = 21) at long-term, which were moderate and asymptomatic overall. In-stent stenosis decreased significantly between short- and long-term follow-ups (31.4 ± 17.0% vs 9.7 ± 13.6%, respectively; p ≤ 0.001). Thromboembolic and hemorrhagic events occurred in 7.5% (n = 7) and 1.1% (n = 1) of patients, respectively. Good clinical outcome (modified Rankin scale: 0-2) was obtained in 97.8% (n = 91) leading to an overall treatment-related morbidity of 2.2% (n = 2). There was no procedural mortality. CONCLUSION Our study shows that FD treatment of unruptured intracranial aneurysms is effective and safe with high occlusion rates and low rates of permanent morbidity at long-term follow-up.
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Affiliation(s)
- Andreas Simgen
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Christian Roth
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Safwan Roumia
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Philipp Dietrich
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | | | - Michael Kettner
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
| | - Umut Yilmaz
- Department of Neuroradiology, Saarland University
Hospital, Homburg/Saar, Germany
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3
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Helwig SA, Ragoschke-Schumm A, Schwindling L, Kettner M, Roumia S, Kulikovski J, Keller I, Manitz M, Martens D, Grün D, Walter S, Lesmeister M, Ewen K, Brand J, Fousse M, Kauffmann J, Zimmer VC, Mathur S, Bertsch T, Guldner J, Magull-Seltenreich A, Binder A, Spüntrup E, Chatzikonstantinou A, Adam O, Kronfeld K, Liu Y, Ruckes C, Schumacher H, Grunwald IQ, Yilmaz U, Schlechtriemen T, Reith W, Fassbender K. Prehospital Stroke Management Optimized by Use of Clinical Scoring vs Mobile Stroke Unit for Triage of Patients With Stroke: A Randomized Clinical Trial. JAMA Neurol 2021; 76:1484-1492. [PMID: 31479116 DOI: 10.1001/jamaneurol.2019.2829] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. Objective To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. Design, Setting, and Participants In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Interventions Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ≥4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). Main Outcomes and Measures The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). Results A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P < .001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P = .02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Conclusions and Relevance Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. Trial Registration ClinicalTrials.gov identifier: NCT02465346.
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Affiliation(s)
- Stefan A Helwig
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | | | - Lenka Schwindling
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Michael Kettner
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Safwan Roumia
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Isabel Keller
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Matthias Manitz
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Martens
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Daniel Grün
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Silke Walter
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Kira Ewen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jannik Brand
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Mathias Fousse
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Jil Kauffmann
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Valerie C Zimmer
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Shrey Mathur
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Jürgen Guldner
- Department of Neurology, Knappschaftsklinikum Saar, Püttlingen, Germany
| | | | - Andreas Binder
- Department of Neurology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Elmar Spüntrup
- Department of Radiology, Klinikum Saarbrücken, Saarbrücken, Germany
| | | | - Oliver Adam
- Medizinische Klinik, Kreiskrankenhaus St Ingbert, St Ingbert, Germany
| | - Kai Kronfeld
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | - Yang Liu
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials (IZKS), Mainz, Germany
| | | | - Iris Q Grunwald
- Department of Neuroscience, Faculty of Medical Science, Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, Southend University Hospital, Southend-on-Sea, United Kingdom
| | - Umut Yilmaz
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Thomas Schlechtriemen
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany.,Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany.,Zweckverband für Rettungsdienst und Feuerwehralarmierung, Saar, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, University Hospital of the Saarland, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, University Hospital of the Saarland, Homburg, Germany
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4
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Grunwald IQ, Kulikovski J, Reith W, Gerry S, Namias R, Politi M, Papanagiotou P, Essig M, Mathur S, Joly O, Hussain K, Wagner V, Shah S, Harston G, Vlahovic J, Walter S, Podlasek A, Fassbender K. Collateral Automation for Triage in Stroke: Evaluating Automated Scoring of Collaterals in Acute Stroke on Computed Tomography Scans. Cerebrovasc Dis 2019; 47:217-222. [PMID: 31216543 DOI: 10.1159/000500076] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/28/2019] [Indexed: 12/27/2022] Open
Abstract
Computed tomography angiography (CTA) collateral scoring can identify patients most likely to benefit from mechanical thrombectomy and those more likely to have good outcomes and ranges from 0 (no collaterals) to 3 (complete collaterals). In this study, we used a machine learning approach to categorise the degree of collateral flow in 98 patients who were eligible for mechanical thrombectomy and generate an e-CTA collateral score (CTA-CS) for each patient (e-STROKE SUITE, Brainomix Ltd., Oxford, UK). Three experienced neuroradiologists (NRs) independently estimated the CTA-CS, first without and then with knowledge of the e-CTA output, before finally agreeing on a consensus score. Addition of the e-CTA improved the intraclass correlation coefficient (ICC) between NRs from 0.58 (0.46-0.67) to 0.77 (0.66-0.85, p = 0.003). Automated e-CTA, without NR input, agreed with the consensus score in 90% of scans with the remaining 10% within 1 point of the consensus (ICC 0.93, 0.90-0.95). Sensitivity and specificity for identifying favourable collateral flow (collateral score 2-3) were 0.99 (0.93-1.00) and 0.94 (0.70-1.00), respectively. e-CTA correlated with the Alberta Stroke Programme Early CT Score (Spearman correlation 0.46, p < 0.001) highlighting the value of good collateral flow in maintaining tissue viability prior to reperfusion. In conclusion, -e-CTA provides a real-time and fully automated approach to collateral scoring with the potential to improve consistency of image interpretation and to independently quantify collateral scores even without expert rater input.
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Affiliation(s)
- Iris Q Grunwald
- Neuroscience, Anglia Ruskin University, School of Medicine, Chelmsford, United Kingdom, .,Southend University Hospital, Essex, United Kingdom, .,Brainomix Limited, Oxford, United Kingdom,
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University Hospital, Homburg, Germany
| | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Hospital, Homburg, Germany
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Politi
- Department for Neuroradiology, Bremen Hospital, Bremen, Germany
| | | | - Marco Essig
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shrey Mathur
- Department of Neurology, Saarland University Hospital, Homburg-Saar, Germany
| | | | - Khawar Hussain
- Neuroscience, Anglia Ruskin University, School of Medicine, Chelmsford, United Kingdom
| | - Viola Wagner
- Department of Neurology, Saarland University Hospital, Homburg-Saar, Germany
| | - Sweni Shah
- Neuroscience, Anglia Ruskin University, School of Medicine, Chelmsford, United Kingdom
| | - George Harston
- Brainomix Limited, Oxford, United Kingdom.,Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Julija Vlahovic
- Neuroscience, Anglia Ruskin University, School of Medicine, Chelmsford, United Kingdom
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg-Saar, Germany
| | | | - Klaus Fassbender
- Department of Neurology, Saarland University Hospital, Homburg-Saar, Germany
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5
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Chriashkova J, Menon N, Chakrabarti A, Guyler P, Kelavkar S, Kuhn A, Kulikovski J, Koduri G, Harston G, Haq I, Podlasek A, Roffe C, Alvarez C, Vani K, Wagner V, Walter S, Grunwald I. Abstract WMP14: e-ASPECTS Improves Sensitivity to Early Ischemic Injury on Acute Computed Tomography Scans. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Nisha Menon
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | | | - Paul Guyler
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | - Shyam Kelavkar
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | - Annalu Kuhn
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | | | - Gouri Koduri
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | - George Harston
- Oxford Univ Hosps NHS Foundation Trust, Oxford, United Kingdom
| | - Inam Haq
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | | | | | | | | | - Viola Wagner
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
| | | | - Iris Grunwald
- Southend Univ Hosp NHS Foundation Trust, Southend, United Kingdom
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6
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Kettner M, Helwig SA, Ragoschke-Schumm A, Schwindling L, Roumia S, Keller I, Martens D, Kulikovski J, Manitz M, Lesmeister M, Walter S, Grunwald IQ, Schlechtriemen T, Reith W, Fassbender K. Prehospital Computed Tomography Angiography in Acute Stroke Management. Cerebrovasc Dis 2017; 44:338-343. [PMID: 29130951 DOI: 10.1159/000484097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. METHODS Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. RESULTS Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. CONCLUSION Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.
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Affiliation(s)
- Michael Kettner
- Department of Neurology, Saarland University Medical Center, Homburg, Germany.,Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | | | | | - Lenka Schwindling
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Safwan Roumia
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Isabel Keller
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Daniel Martens
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Johann Kulikovski
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Matthias Manitz
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Silke Walter
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Iris Quasar Grunwald
- Department of Neuroscience, Anglia Ruskin University, Chelmsford, United Kingdom
| | | | - Wolfgang Reith
- Department of Neuroradiology, Saarland University Medical Center, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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