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Maimaiti M, Li C, Cheng M, Zhong Z, Hu J, Yang L, Zhang L, Hong Z, Song J, Pan M, Ma X, Cui S, Zhang P, Hao H, Wang C, Hu H. Blocking cGAS-STING pathway promotes post-stroke functional recovery in an extended treatment window via facilitating remyelination. MED 2024; 5:622-644.e8. [PMID: 38663402 DOI: 10.1016/j.medj.2024.03.018] [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: 02/13/2023] [Revised: 02/15/2024] [Accepted: 03/27/2024] [Indexed: 06/17/2024]
Abstract
BACKGROUND Ischemic stroke is a major cause of worldwide death and disability, with recombinant tissue plasminogen activator being the sole effective treatment, albeit with a limited treatment window. The cyclic GMP-AMP synthase (cGAS) and stimulator of interferon genes (STING) pathway is emerging as the major DNA-sensing pathway to invoke immune responses in neuroinflammatory disorders. METHODS By performing a series of neurobehavioral assessments, electrophysiological analysis, high-throughput sequencing, and cell-based assays based on the transient middle cerebral artery occlusion (tMCAO) mouse stroke model, we examined the effects and underlying mechanisms of genetic and pharmacological inhibition of the cGAS-STING pathway on long-term post-stroke neurological functional outcomes. FINDINGS Blocking the cGAS-STING pathway, even 3 days after tMCAO, significantly promoted functional recovery in terms of white matter structural and functional integrity as well as sensorimotor and cognitive functions. Mechanistically, the neuroprotective effects via inhibiting the cGAS-STING pathway were contributed not only by inflammation repression at the early stage of tMCAO but also by modifying the cell state of phagocytes to facilitate remyelination at the sub-acute phase. The activation of the cGAS-STING pathway significantly impeded post-stroke remyelination through restraining myelin debris uptake and degradation and hindering oligodendrocyte differentiation and maturation. CONCLUSIONS Manipulating the cGAS-STING pathway has an extended treatment window in promoting long-term post-stroke functional recovery via facilitating remyelination in a mouse stroke model. Our results highlight the roles of the cGAS-STING pathway in aggregating stroke pathology and propose a new way for improving functional recovery after ischemic stroke. FUNDING This work was primarily funded by the National Key R&D Program of China.
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Affiliation(s)
- Munire Maimaiti
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Chenhui Li
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China.
| | - Mingxing Cheng
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Ziwei Zhong
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Jiameng Hu
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Lei Yang
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Lele Zhang
- Central Laboratory, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ze Hong
- School of Pharmacy, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jinyi Song
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Mingyu Pan
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Xiaonan Ma
- Cellular and Molecular Biology Center, China Pharmaceutical University, Nanjing, China
| | - Shufang Cui
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
| | - Peng Zhang
- Central Laboratory, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Haiping Hao
- Jiangsu Provincial Key Laboratory of Drug Metabolism and Pharmacokinetics, State Key Laboratory of Natural Medicines, Key Laboratory of Drug Metabolism, China Pharmaceutical University, Nanjing, China; School of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Chen Wang
- State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing, China.
| | - Haiyang Hu
- Central Laboratory, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Chongqing Innovation Institute of China Pharmaceutical University, Chongqing, China.
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Yin CY, Lian YP, Xu JD, Liu CM, Cai JL, Zhu L, Wang DJ, Luo LB, Yan XJ. Study on network pharmacology of Ginkgo biloba extract against ischaemic stroke mechanism and establishment of UPLC-MS/MS methods for simultaneous determination of 19 main active components. PHYTOCHEMICAL ANALYSIS : PCA 2024; 35:254-270. [PMID: 37758241 DOI: 10.1002/pca.3286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Ginkgo biloba extract (GBE) is an effective substance from traditional Chinese medicine (TCM) G. biloba for treating ischaemic stroke (IS). However, its active ingredients and mechanism of action remain unclear. OBJECTIVES This study aimed to reveal the potential active component group and possible anti-IS mechanism of GBE. MATERIALS AND METHODS The network pharmacology method was used to reveal the possible anti-IS mechanism of these active ingredients in GBE. An ultra-high-performance liquid chromatography triple quadrupole electrospray tandem mass spectrometry (UPLC-MS/MS) method was established for the simultaneous detection of the active ingredients of GBE. RESULTS The active components of GBE anti-IS were screened by literature integration. Network pharmacology results showed that the anti-IS effect of GBE is achieved through key active components such as protocatechuic acid, bilobalide, ginkgolide A, and so on. Gene Ontology (GO) function and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis showed that the possible anti-IS mechanism of GBE is regulating the PI3K-Akt signalling pathway and other signal pathways closely related to inflammatory response and apoptosis regulation combined with AKT1, MAPK, TNF, ALB, CASP3, and other protein targets. Nineteen main constituents in seven batches of GBE were successfully analysed using the established UPLC-MS/MS method, and the results showed that the content of protocatechuic acid, gallic acid, ginkgolide A, and so forth was relatively high, which was consistent with network pharmacology results, indicating that these ingredients may be the key active anti-IS ingredients of GBE. CONCLUSION This study revealed the key active components and the anti-IS mechanism of GBE. It also provided a simple and sensitive method for the quality control of related preparations.
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Affiliation(s)
- Chun-Yan Yin
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Yuan-Pei Lian
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Jian-Da Xu
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Chan-Ming Liu
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Jia-Li Cai
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Li Zhu
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Di-Jun Wang
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Li-Bo Luo
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
| | - Xiao-Jing Yan
- Changzhou Key Laboratory of Human Use Experience Research & Transformation of Menghe Medical School, Changzhou Hospital Affiliated to Nanjing University of Chinese Medicine, Changzhou, China
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Teng C, Lv W, Chen Y, Liu L, Yin J, Li S, Min Z, Zhang Q, He W, Ma K, Li X, Cao X, Xin H. Enhanced the treatment of ischemic stroke through intranasal temperature-sensitive hydrogels of edaravone and borneol inclusion complex. Int J Pharm 2024; 651:123748. [PMID: 38154533 DOI: 10.1016/j.ijpharm.2023.123748] [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: 10/24/2023] [Revised: 11/29/2023] [Accepted: 12/24/2023] [Indexed: 12/30/2023]
Abstract
Since ischemic stroke occurs by a combination of multiple mechanisms, therapies that modulate multiple mechanisms are required for its treatment. The combination of edaravone (EDA) and borneol can significantly ameliorate the symptoms of neurological deficits in cerebral ischemia-reperfusion model in rats. In this study, the solubility of borneol and edaravone was improved by hydroxypropyl-β-cyclodextrin and PEG400. Furthermore, a nasal temperature-sensitive hydrogel containing both edaravone and borneol inclusion complex (EDA-BP TSGS) was developed to overcome the obstacles of ischemic stroke treatment including the obstruction of the blood-brain barrier (BBB) and the unavailability and untimely of intravenous injection. The effectiveness of the thermosensitive hydrogel was investigated in transient middle cerebral artery occlusion/reperfusion model rats (MCAO/R). The results showed that EDA-BP TSGS could significantly alleviate the symptoms of neurological deficits and decrease the cerebral infarct area and the degree of brain damage. In summary, nasal EDA-BP TSGS is a secure and effective brain-targeting formulation that may provide a viable option for the clinical prophylaxis and treatment of ischemic stroke.
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Affiliation(s)
- Chuanhui Teng
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Wei Lv
- Department of Pharmacy, The Affiliated Jiangyin Hospital of Xuzhou Medical University, Wuxi 214400, China
| | - Yuqin Chen
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Linfeng Liu
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Jiaqing Yin
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Shengnan Li
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Zhiyi Min
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Qi Zhang
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Weichong He
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Kunfang Ma
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Xinrui Li
- Department of Pharmacy, Sir Run Run Hospital, Nanjing Medical University, Nanjing 211166, China.
| | - Xiang Cao
- Department of Pharmacy, Kangda College of Nanjing Medical University, Lianyungang 222000, China.
| | - Hongliang Xin
- Department of Pharmaceutics, School of Pharmacy, Nanjing Medical University, Nanjing 211166, China.
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Liu L, Li Z, Zhou H, Duan W, Huo X, Xu W, Li S, Nie X, Liu H, Liu J, Sun D, Wei Y, Zhang G, Yuan W, Zheng L, Liu J, Wang D, Miao Z, Wang Y. Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update. Stroke Vasc Neurol 2023; 8:e3. [PMID: 38158224 PMCID: PMC10800268 DOI: 10.1136/svn-2023-002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases. METHODS We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee. RESULTS This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management. CONCLUSIONS This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hongyu Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Cerebral Vascular Disease Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Weihai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujuan Li
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huihui Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinjie Liu
- Department of General Medicine, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Dapeng Sun
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guitao Zhang
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weizhuang Yuan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lina Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zhongrong Miao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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Li J, Zhang T, Liu K, Hu G. Protective effects and mechanisms of Yi Qi Huo Xue Fang in cerebral ischemic stroke based on network pharmacology and experimental verification. JOURNAL OF ETHNOPHARMACOLOGY 2023; 314:116611. [PMID: 37169318 DOI: 10.1016/j.jep.2023.116611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Yi Qi Huo Xue Fang (YQHXF) is an effective formula for treating cerebral ischemic stroke (CIS). However, its active ingredients and mechanism of action remain unclear. AIM OF THE STUDY This study aimed to reveal the mechanism of action of YQHXF in the treatment of ischemic stroke based on network pharmacology and experimental validation. MATERIALS AND METHODS This study identified the chemical components in YQHXF and the components absorbed by rat serum based on UPLC-Q-TOF/MS technology and used network pharmacology to predict key candidate targets. A protein-protein-interaction (P-P-I) network was constructed using String 11.0 database and Cytoscape, and R software for gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment analysis. Finally, molecular docking combined with animal experiments was used to verify network pharmacology results. RESULTS This study identified and confirmed 36 chemical components of YQHXF and five chemical ingredients that were absorbed into the blood of rats and screened 66 key candidate targets. All targets in the P-P-I network were mainly related to inflammation and vascular processes. KEGG enrichment results revealed that these 66 key candidate targets were primarily involved in the "AGE-RAGE signaling pathway," "TNF-α signaling pathway, and "T cell receptor signaling pathway." Molecular docking results revealed that Prostaglandin-endoperoxidase synthase 2(PTGS-2), Nitric oxide synthase, endothelial (NOS3), and peroxisome proliferator-activated receptor gamma (PPARG) were more stably bound to their active ingredients. Animal experiments demonstrated that YQHXF promoted M2 polarization, inhibited M1 polarization in microglia, and promoted angiogenesis, which may be related to the PPARG pathway. CONCLUSION This study revealed the key active components and effective targets of YQHXF, identified the mechanism of action of YQHXF, laid the foundation for further research on YQHXF, and provided ideas for developing new drugs for CIS.
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Affiliation(s)
- Jiamin Li
- The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, 410021, China; Hunan University of Chinese Medicine, Changsha, 410208, China.
| | - Tiantian Zhang
- The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, 410021, China; Hunan University of Chinese Medicine, Changsha, 410208, China.
| | - Kan Liu
- The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, 410021, China.
| | - Guoheng Hu
- The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, 410021, China; Hunan University of Chinese Medicine, Changsha, 410208, China.
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Wang Z, Ji K, Fang Q. Low-dose vs. standard-dose intravenous alteplase for acute ischemic stroke with unknown time of onset. Front Neurol 2023; 14:1165237. [PMID: 37188314 PMCID: PMC10175638 DOI: 10.3389/fneur.2023.1165237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Background Standard-dose intravenous alteplase for acute ischemic stroke (AIS) in the unknown or extended time window beyond 4.5 h after symptom onset is both effective and safe for certain patients who were selected based on multimodal neuroimaging. However, uncertainty exists regarding the potential benefit of using low-dose alteplase among the Asian population outside the 4.5-h time window. Methods Consecutive AIS patients who received intravenous alteplase between 4.5 and 9 h after symptom onset or with an unknown time of onset guided by multimodal computed tomography (CT) imaging were identified from our prospectively maintained database. The primary outcome was excellent functional recovery, defined as having a modified Rankin scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (an mRS score of 0-2 at 90 days), early major neurologic improvement (ENI), early neurologic deterioration (END), any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Propensity score matching (PSM) and multivariable logistic regression models were used to adjust for confounding factors and compare the clinical outcomes between the low- and standard-dose groups. Results From June 2019 to June 2022, a total of 206 patients were included in the final analysis, of which 143 were treated with low-dose alteplase and 63 were treated with standard-dose alteplase. After accounting for confounding factors, we observed that there were no statistically significant differences between the standard- and low-dose groups with respect to excellent functional recovery [adjusted odds ratio = 1.22 (aOR), 95% confidence interval (CI): 0.62-2.39; adjusted rate difference (aRD) = 4.6%, and 95% CI: -11.2 to 20.3%]. Patients of both groups had similar rates of functional independence, ENI, END, any ICH, sICH, and 90-day mortality. In the subgroup analysis, patients aged ≥70 years were more likely to achieve excellent functional recovery when receiving standard-dose rather than low-dose alteplase. Conclusion The effectiveness of low-dose alteplase might be comparable to that of standard-dose alteplase in AIS patients aged <70 years with favorable perfusion-imaging profiles in the unknown or extended time window but not in those aged ≥70 years. Furthermore, low-dose alteplase did not significantly reduce the risk of sICH compared to standard-dose alteplase.
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Zhang Z, Yang H, Tu Z, Nepal G, Ojha R, Xi Y, Qiao J, Hu M, Li C, Lin F, Zhou L, Jin P, Hou S. Multicentre registration of wake-up stroke in China (MCRWUSC): a protocol for a prospective, multicentre, registry-based cohort study. BMJ Open 2022; 12:e060818. [PMID: 36357004 PMCID: PMC9660665 DOI: 10.1136/bmjopen-2022-060818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Wake-up stroke (WUS) is a type of acute ischaemic stroke (AIS) that occurs during sleep with unknown time of symptom onset. The best treatment is usually not suitable for WUS, as thrombolysis is usually provided to patients who had a symptomatic AIS within a definite 4.5 hours, and WUS remains a therapeutic quandary. Efforts to explore the onset time characteristics of patients who had a WUS and the risk factors affecting poor prognosis support a role for providing new insights by performing multicentre cohort study. METHODS AND ANALYSIS This multicentre, nationwide prospective registry will include 21 comprehensive stroke centres, with a goal of recruiting 550 patients who had a WUS in China. In this study, clinical data including patient's clinical characteristics, stroke onset time, imaging findings, therapeutic interventions and prognosis (the National Institutes of Health Stroke Scale Score and the modified Rankin Scale Score at different time points) will be used to develop prediction models for stroke onset time and prognostic evaluation using the fast-processing of ischemic stroke software. The purpose of this study is to identify risk factors influencing prognosis, to investigate the relationship between the time when the symptoms are found and the actual onset time and to establish an artificial intelligence-based model to predict the prognosis of patients who had a WUS. ETHICS AND DISSEMINATION This study is approved by the ethics committee of Shanghai Pudong Hospital (Shanghai, China) and rest of all participating centres. The findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER ChiCTR2100049133.
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Affiliation(s)
- Zengyu Zhang
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Hualan Yang
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Zhilan Tu
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Yan Xi
- Department of Radiology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Jianlan Qiao
- Department of Radiology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Mengting Hu
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Chao Li
- School of Pharmacy, Hubei University of Science and Technology, Hubei, China
| | - Fuchun Lin
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Lili Zhou
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Pengpeng Jin
- Department of Chronic Disease Management, Shanghai Pudong Hospital, Fudan University, Shanghai, China
| | - Shuangxing Hou
- Department of Neurology, Shanghai Pudong Hospital, Fudan University, Shanghai, China
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Application of Multimodal Magnetic Resonance Imaging in Green Channel of Acute and Hyperacute Ischemic Stroke. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:2452282. [PMID: 35935321 PMCID: PMC9337922 DOI: 10.1155/2022/2452282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/24/2022] [Accepted: 07/04/2022] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to observe the effects of multimodal magnetic resonance imaging (MRI) in the green channel of acute and hyperacute ischemic strokes, in order to better guide clinical treatment. The clinical data of 126 patients with acute and hyperacute ischemic stroke who received interventional treatment in the emergency green channel was collected retrospectively. The patients who received multimodal computed tomography (CT) were included in the CT group. Patients who underwent multimodal MRI examinations were included in the MRI group, and the door-to-needle time (DNT), neurological function, and prognosis of the two groups were compared. The result turned out that among the 126 patients included, 40 patients underwent CT examination (CT group) and 86 patients underwent MRI examination (MRI group). A comparison of general data between the CT group and the MRI group showed
. The MRI group’s DNT time (61.23 ± 9.32) min was shorter than that of the CT group (87.22 ± 14.26) min,
. Through comparison, the
values of mRS scores and NIHSS scores in both groups were greater than 0.05. After treatment, the mRS score and NIHSS score of the MRI group was lower, with
. According to the results of this study, it can be concluded that emergency multimodal MRI could shorten the DNT time of patients with acute and hyperacute ischemic stroke, reduce the degree of neurological impairment, and improve the prognosis.
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Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Evaluation of stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in delayed intravenous thrombolysis patients (beyond 4.5 hours). J Stroke Cerebrovasc Dis 2022; 31:106384. [PMID: 35182948 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/05/2022] [Accepted: 01/30/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES the efficacy of delayed intravenous tissue plasminogen activator (tPA), beyond the 4.5 h window, is evolving. Advanced age and high admission National Institutes of Health Stroke Scale (NIHSS) score are proposed to adversely affect the outcome of delayed thrombolysis and limit the inclusion criteria. The summation of patient age and admission NIHSS score was introduced as the SPAN-100 index as a tool of prediction of the clinical outcome after acute ischemic stroke (AIS). We aimed to assess the SPAN-100 index in AIS thrombolysed patients after 4.5 h. MATERIALS AND METHODS The SPAN-100 index was applied to AIS patients receiving delayed IV thrombolysis (IVT) after 4.5 h. Patients demographics, risk factors, clinical, laboratory and radiological data, mismatch evidence, treatment onset and modality, NIHSS score at baseline and at discharge, and 3 months follow-up modified Rankin Scale (mRS) were reviewed. SPAN-100 score ≥ 100 is classified as SPAN-100 positive while score < 100 is SPAN-100 negative. Clinical outcomes, death and intracerebral hemorrhage (ICH) incidences were compared between SPAN-100 positive and negative groups. RESULTS SPAN-100-positive delayed IVT-patients (11/136) had a 6-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 6.34; 95% CI 1.59-25.24 p=0.004), however there was no relation between the SPAN-100 positivity and mortality or ICH. CONCLUSION SPAN-100-positive patients are more likely to achieve non-favorable outcome with delayed IVT in comparison to the SPAN-100-negative patients. SPAN-100 index may influence the eligibility criteria of delayed thrombolysis.
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Affiliation(s)
- Nada Elsaid
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy; Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt.
| | - Guido Bigliardi
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Maria Luisa Dell'Acqua
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Laura Vandelli
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Ludovico Ciolli
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Livio Picchetto
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Giuseppe Borzì
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Riccardo Ricceri
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Roberta Pentore
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Stefano Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Stefano Meletti
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy.
| | - Ahmed Saied
- Stroke Unit - Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Italy; Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt.
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10
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Measuring the effect of thrombosis, thrombus maturation and thrombolysis on clot mechanical properties in an in-vitro model. J Biomech 2021; 129:110731. [PMID: 34601216 DOI: 10.1016/j.jbiomech.2021.110731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
Changes in acute ischemic stroke thrombi structure and composition may result in significant differences in treatment responsiveness. Ischemic stroke patients are often treated with a thrombolytic agent to dissolve thrombi, however these patients may subsequently undergo mechanical thrombectomy to remove the occlusive clot. We set out to determine if rt-PA thrombolysis treatment of blood clots changes their mechanical properties, which in turn may impact mechanical thrombectomy. Using a design-of-experiment approach, ovine clot analogues were prepared with varying composition and further exposed to different levels of compaction force to simulate the effect of arterial blood pressure. Finally, clots were treated with three r-tPA doses for different durations. Clot mass and mechanical behaviour was analysed to assess changes due to (i) Platelet driven contraction (ii) Compaction force and (iii) Thrombolysis. Clots that were exposed to r-tPA for longer duration showed significant reduction in clot mass (p < 0.001). Exposure time to r-tPA (p < 0.001) was shown to be an independent predictor of lower clot stiffness. A decrease in energy dissipation ratio during mechanical compression was associated with longer exposure time in r-tPA (p = 0.001) and a higher platelet concentration ratio (p = 0.018). The dose of r-tPA was not a significant factor in reducing clot mass or changing mechanical properties of the clots. Fibrinolysis reduces clot stiffness which may explain increased distal clot migration observed in patients treated with r-tPA and should be considered as a potential clot modification factor before mechanical thrombectomy.
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Brodtmann A, Werden E, Khlif MS, Bird LJ, Egorova N, Veldsman M, Pardoe H, Jackson G, Bradshaw J, Darby D, Cumming T, Churilov L, Donnan G. Neurodegeneration Over 3 Years Following Ischaemic Stroke: Findings From the Cognition and Neocortical Volume After Stroke Study. Front Neurol 2021; 12:754204. [PMID: 34744989 PMCID: PMC8570373 DOI: 10.3389/fneur.2021.754204] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/27/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Stroke survivors are at high risk of dementia, associated with increasing age and vascular burden and with pre-existing cognitive impairment, older age. Brain atrophy patterns are recognised as signatures of neurodegenerative conditions, but the natural history of brain atrophy after stroke remains poorly described. We sought to determine whether stroke survivors who were cognitively normal at time of stroke had greater total brain (TBV) and hippocampal volume (HV) loss over 3 years than controls. We examined whether stroke survivors who were cognitively impaired (CI) at 3 months following their stroke had greater brain volume loss than cognitively normal (CN) stroke participants over the next 3 years. Methods: Cognition And Neocortical Volume After Stroke (CANVAS) study is a multi-centre cohort study of first-ever or recurrent adult ischaemic stroke participants compared to age- and sex-matched community controls. Participants were followed with MRI and cognitive assessments over 3 years and were free of a history of cognitive impairment or decline at inclusion. Our primary outcome measure was TBV change between 3 months and 3 years; secondary outcomes were TBV and HV change comparing CI and CN participants. We investigated associations between group status and brain volume change using a baseline-volume adjusted linear regression model with robust standard error. Results: Ninety-three stroke (26 women, 66.7 ± 12 years) and 39 control participants (15 women, 68.7 ± 7 years) were available at 3 years. TBV loss in stroke patients was greater than controls: stroke mean (M) = 20.3 cm3 ± SD 14.8 cm3; controls M = 14.2 cm3 ± SD 13.2 cm3; [adjusted mean difference 7.88 95%CI (2.84, 12.91) p-value = 0.002]. TBV decline was greater in those stroke participants who were cognitively impaired (M = 30.7 cm3; SD = 14.2 cm3) at 3 months (M = 19.6 cm3; SD = 13.8 cm3); [adjusted mean difference 10.42; 95%CI (3.04, 17.80), p-value = 0.006]. No statistically significant differences in HV change were observed. Conclusions: Ischaemic stroke survivors exhibit greater neurodegeneration compared to stroke-free controls. Brain atrophy is greater in stroke participants who were cognitively impaired early after their stroke. Early cognitive impairment was associated greater subsequent atrophy, reflecting the combined impacts of stroke and vascular brain burden. Atrophy rates could serve as a useful biomarker for trials testing interventions to reduce post-stroke secondary neurodegeneration. Clinical Trail Registration:http://www.clinicaltrials.gov, identifier: NCT02205424.
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Affiliation(s)
- Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, Florey Institute and University of Melbourne, Parkville, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Emilio Werden
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Mohamed Salah Khlif
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Laura J Bird
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Natalia Egorova
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, Florey Institute and University of Melbourne, Parkville, VIC, Australia.,Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Michele Veldsman
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Heath Pardoe
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, United States
| | - Graeme Jackson
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer Bradshaw
- Department of Clinical Neuropsychology, Austin Health, Heidelberg, VIC, Australia
| | - David Darby
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Dementia Research Centre, Florey Institute and University of Melbourne, Parkville, VIC, Australia
| | - Toby Cumming
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Leonid Churilov
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Geoffrey Donnan
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia.,Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
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Elsaid N, Bigliardi G, Dell'Acqua ML, Vandelli L, Ciolli L, Picchetto L, Borzì G, Ricceri R, Pentore R, Vallone S, Meletti S, Saied A. Factors affecting the outcome of delayed intravenous thrombolysis (>4.5hours). Rev Neurol (Paris) 2021; 177:1266-1275. [PMID: 34384630 DOI: 10.1016/j.neurol.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/31/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Evidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS). METHODS Data of patients with AIS who received intravenous thrombolytic after 4.5hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24hours, 7days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS). RESULTS We report 136 patients treated by intravenous tPA between 4.53 and 19.75hours with average duration of 5.7h. The ASPECT score of our patients was≥7. Sixty-four cases showed intracranial arterial occlusion. Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24hours occurred in 114 (83.8%) patients. At 90days, 91 patients (67%) achieved good outcome (mRS 0-2), while 45 (33%) had bad outcome (mRS 3-6). Age, endovascular treatment, NIHSS, AF, and HT were significantly higher in the bad outcome group. Age (P=0.001, OR: 1.099, 95% CI: 1.042-1.160) and baseline NIHSS were predictive of the poor outcome (P=0.002, OR: 1.151, 95% CI: 1.055-1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively. CONCLUSION Increased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.
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Affiliation(s)
- N Elsaid
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy; Department of Neurology, Mansoura University, Mansoura, Egypt.
| | - G Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - M L Dell'Acqua
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Ciolli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - L Picchetto
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - G Borzì
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - R Ricceri
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - R Pentore
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - S Vallone
- Neuroradiology, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - S Meletti
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy
| | - A Saied
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Ospedale Civile di Baggiovara, AOU di Modena, Modena, Italy; Department of Neurology, Mansoura University, Mansoura, Egypt
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