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Jameie M, Heydari S, Ghabaee M, Amirifard H. Two ischemic stroke events within 48 h: a case report of an unusual presentation of thrombotic thrombocytopenic purpura. BMC Neurol 2023; 23:47. [PMID: 36709264 PMCID: PMC9883936 DOI: 10.1186/s12883-023-03073-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/16/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) considers a rare cause of ischemic stroke (IS). We reported a case of a newly diagnosed patient with acquired immune-mediated TTP (iTTP), in whom two IS events developed during 48 h. CASE PRESENTATION A 59-year-old diabetic male was presented to the hospital 24 h after symptoms onset, including left hemiparesis, dysarthria, and decreased consciousness. A brain CT scan was performed with the suspicion of acute IS, indicating infarct lesions in the right middle cerebral artery (MCA) territory. The patient was not eligible for thrombolytic therapy due to admission delay. Over the next 24 h, the patient's neurological condition deteriorated, and the second brain CT scan showed new ischemic lesions in the left MCA territory. Initial laboratory evaluation indicated thrombocytopenia without evidence of anemia. However, in the following days, thrombocytopenia progressed, and microangiopathic hemolytic anemia (MAHA) developed. The ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent plasma exchange activity and inhibitors assay confirmed the diagnosis of iTTP. The patient underwent and pulse IV methylprednisolone. Rituximab was also added due to the refractory course of the disease. After a prolonged hospital course, he had considerable neurologic recovery and was discharged. CONCLUSIONS Clinicians should consider two points. First, TTP should be considered in any patient presenting with IS and having thrombocytopenia or anemia without other symptoms of TTP. Second, worsening the patient's condition during hospitalization may indicate a new stroke and should be investigated immediately.
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Affiliation(s)
- Melika Jameie
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran ,grid.411746.10000 0004 4911 7066Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Sanaz Heydari
- grid.414574.70000 0004 0369 3463Neurology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojdeh Ghabaee
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Amirifard
- grid.411705.60000 0001 0166 0922Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.
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Affiliation(s)
- Samuel A Berkman
- Division of Hematology-Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shlee S Song
- Department of Neurology, Comprehensive Stroke Center Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Tomich C, Debruxelles S, Delmas Y, Sagnier S, Poli M, Olindo S, Renou P, Rouanet F, Sibon I. Immune-Thrombotic Thrombocytopenic Purpura is a Rare Cause of Ischemic Stroke in Young Adults: Case Reports and Literature Review. J Stroke Cerebrovasc Dis 2018; 27:3163-3171. [PMID: 30217637 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/13/2018] [Accepted: 07/04/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (i-TTP), related to acquired ADAMTS-13 dysfunction, can lead to various neurological symptoms including ischemic stroke. To date the clinical, radiological, and biological characteristics of patients having a stroke as the inaugural manifestation of i-TTP are largely unknown. METHODS Probable immune-TTP was defined by a low ADAMTS-13 activity associated with the presence of ADAMTS-13 inhibitors and/or favorable clinicobiological response under immunological treatments. The clinical, radiological, biological data and outcome under treatment are described in a cohort of 17 patients coming from 3 local cases and a literature review. RESULTS Fourteen of the 17 patients were female and the mean age was 41 years. None of the patients had the classical pentad of TTP. Only 41% had a combination of thrombocythemia and hemolysis. Stroke was multifocal in 35% and included large artery strokes. No adverse event was observed following intravenous thrombolysis. Refractory and relapsing forms were observed in 47%. DISCUSSION The clinical, radiological, and biological presentation of patients with stroke as the inaugural presentation of i-TTP is heterogeneous. This diagnosis should be discussed in every young adult with ischemic stroke of undetermined source.
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MESH Headings
- ADAMTS13 Protein/immunology
- Adrenal Cortex Hormones/therapeutic use
- Adult
- Aged
- Autoantibodies/blood
- Biomarkers/blood
- Brain Ischemia/diagnostic imaging
- Brain Ischemia/etiology
- Diffusion Magnetic Resonance Imaging
- Disability Evaluation
- Female
- Humans
- Male
- Middle Aged
- Plasma Exchange
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Purpura, Thrombotic Thrombocytopenic/blood
- Purpura, Thrombotic Thrombocytopenic/complications
- Purpura, Thrombotic Thrombocytopenic/diagnosis
- Purpura, Thrombotic Thrombocytopenic/therapy
- Risk Factors
- Stroke/diagnostic imaging
- Stroke/etiology
- Treatment Outcome
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Affiliation(s)
- Cyrielle Tomich
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France.
| | - Sabrina Debruxelles
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Yahsou Delmas
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Sharmila Sagnier
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Mathilde Poli
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Stéphane Olindo
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Pauline Renou
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - François Rouanet
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, CHU de Bordeaux, Bordeaux, France / Except Yahsou Delmas: Department of Nephrology, CHU de Bordeaux, Bordeaux, France
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Mentz H, Horan M, Payton A, Ollier W, Pendleton N, Hamdy S. Homozygosity in the ApoE 4 polymorphism is associated with dysphagic symptoms in older adults. Dis Esophagus 2015; 28:97-103. [PMID: 24261350 DOI: 10.1111/dote.12162] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Apolipoprotein E (ApoE) is the most well-described genetic risk factor for Alzheimer's disease and nonpathological cognitive decline. While possession of the E2 allele may have protective properties, substantial research evidence suggests the E4 allele increases the risk of cognitive degeneration. As neurodegenerative processes are implicated in swallowing dysfunction, we hypothesized that the presence of ApoE 4 would be predictive of dysphagia symptoms in older adults. Eight hundred members of a genetically well characterized community dwelling elderly cohort received the Sydney oropharyngeal dysphagia questionnaire via mail. Cognitive function was also measured using the modified Telephone Interview of Cognitive Status (TiCS-m) and depression with the Geriatric Depression Score (GDS). ApoE allele was genotyped on blood samples from all subjects and data analyzed using standard statistical software (SPSS version 16). Completed questionnaire response rate was 79% (23.5% men, 76.5% women; mean age 81 ± 5 years; range 69-98 years). Possession of one or more of the ApoE 4 and 2 alleles was found in 23.5% and 16%, respectively. Swallowing score was significantly related to GDS (rho 0.133, P < 0.001**) and age (rho 0.107, P < 0.007**) but not general cognitive function as measured by TICS-m. Self-reported swallowing function was not significantly associated with heterozygosity of any allele or homozygosity for E2 or E3 alleles. Although infrequent (1.1% of all subjects) ApoE E4 homozygosity was significantly associated with higher swallowing scores compared to all other allele combinations (P = 0.033) and while attenuated, was still predicted in multivariate regression modeling (B = 0.812; SE = 0.323; P = 0.012). We report the association between ApoE 4 homozygous genotype and self-reported oropharyngeal dysphagia symptoms in community-dwelling older adults. As this association is weakened by the multivariate analysis and the population frequency of ApoE 4 allele homozygosity is low, this finding while intriguing requires replication in larger independent cohorts.
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Affiliation(s)
- H Mentz
- Centre for Gastrointestinal Sciences, Institute of Inflammation and Repair, University of Manchester (part of the Manchester Academic Health Sciences Centre (MAHSC)), Manchester, UK
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Maaijwee NAMM, Rutten-Jacobs LCA, Schaapsmeerders P, van Dijk EJ, de Leeuw FE. Ischaemic stroke in young adults: risk factors and long-term consequences. Nat Rev Neurol 2014; 10:315-25. [PMID: 24776923 DOI: 10.1038/nrneurol.2014.72] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Contrary to trends in most other diseases, the average age of ischaemic stroke onset is decreasing, owing to a rise in the incidence of stroke among 'young' individuals (under 50 years of age). This Review provides a critical overview of the risk factors and aetiology of young ischaemic stroke and addresses its long-term prognosis, including cardiovascular risk, functional outcome and psychosocial consequences. We highlight the diminishing role of 'rare' risk factors in the pathophysiology of young stroke in light of the rising prevalence of 'traditional' vascular risk factors in younger age groups. Long-term prognosis is of particular interest to young patients, because of their long life expectancy and major responsibilities during a demanding phase of life. The prognosis of young stroke is not as favourable as previously thought, with respect either to mortality or cardiovascular disease or to psychosocial consequences. Therefore, secondary stroke prevention is probably a life-long endeavour in most young stroke survivors. Due to under-representation of young patients in past trials, new randomized trials focusing on this age group are needed to confirm the benefits of long-term secondary preventive medication. The high prevalence of poor functional outcome and psychosocial problems warrants further study to optimize treatment and rehabilitation for these young patients.
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Affiliation(s)
- Noortje A M M Maaijwee
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Loes C A Rutten-Jacobs
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Pauline Schaapsmeerders
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Ewoud J van Dijk
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Centre for Neuroscience, PO Box 9101, 6500 HB, Nijmegen, Netherlands
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Yamamoto FI. Ischemic stroke in young adults: an overview of etiological aspects. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:462-6. [PMID: 22699545 DOI: 10.1590/s0004-282x2012000600014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 01/17/2012] [Indexed: 11/22/2022]
Abstract
Stroke affects mainly people aged over 65 years, and atherosclerosis predominates as the main etiopathogenic factor in ischemic stroke (IS). On the other hand, cardiac embolism and arterial dissection are the most frequent causes of IS in patients aged less than 45 years. However, inappropriate control of traditional vascular risk factors in young people may be causing a significant increase of atherosclerosis-related IS in this population. Furthermore, a variety of etiologies, many of them uncommon, must be investigated. In endemic regions, neurocysticercosis and Chagas' disease deserve consideration. Undetermined cause has been still reported in as many as one third of young stroke patients.
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Affiliation(s)
- Fábio Iuji Yamamoto
- Division of Neurology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Cramer SC, Procaccio V. Correlation between genetic polymorphisms and stroke recovery: analysis of the GAIN Americas and GAIN International Studies. Eur J Neurol 2012; 19:718-24. [PMID: 22221491 DOI: 10.1111/j.1468-1331.2011.03615.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Recovery after stroke occurs on the basis of specific molecular events. Genetic polymorphisms associated with impaired neural repair or plasticity might reduce recovery from stroke and might also account for some of the intersubject variability in stroke recovery. This study hypothesized that the ApoE ε4 polymorphism and the val(66) met polymorphism for brain-derived neurotrophic factor (BDNF) are each associated with poorer outcome after stroke. Associations with mitochondrial genotype were also explored. METHODS Genotypes were determined in 255 stroke patients who also received behavioral evaluations in the Glycine Antagonist In Neuroprotection (GAIN) clinical trials. The primary outcome measure was recovery during the first month post-stroke, as this is the time when neural repair is at a maximum and so when genetic influences might have their largest impact. Two secondary outcome measures at 3 months post-stroke were also examined. RESULTS Genotype groups were similar acutely post-stroke. Presence of the ApoE ε4 polymorphism was associated with significantly poorer recovery over the first month post-stroke (P = 0.023) and with a lower proportion of subjects with minimal or no disability (modified Rankin score 0-1, P = 0.01) at 3 months post-stroke. Indeed, those with this polymorphism were approximately half as likely to achieve minimal or no disability (18.2%) versus those with polymorphism absent (35.5%). Findings were confirmed in multivariate models. Results suggested possible effects from the val(66) met BDNF polymorphism and from the R0 mitochondrial DNA haplotype. CONCLUSIONS Genetic factors, particularly the ApoE ε4 polymorphism, might contribute to variability in outcomes after stroke.
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Affiliation(s)
- S C Cramer
- Department of Neurology and Anatomy, University of California, Irvine, CA, USA.
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Risk of cerebrovascular events in persons with and without HIV: a Danish nationwide population-based cohort study. AIDS 2011; 25:1637-46. [PMID: 21646903 DOI: 10.1097/qad.0b013e3283493fb0] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the risk of cerebrovascular events (CVEs) in HIV-infected individuals and evaluate the impact of proven risk factors, injection drug abuse (IDU), immunodeficiency, HAART and family-related risk factors. DESIGN Nationwide, population-based cohort study. METHODS The study population included all Danish HIV-infected individuals, a population-based comparison cohort and parents of both cohorts - all with no prior cerebral comorbidity. We computed incidence rate ratios (IRRs) of overall CVEs and CVEs with and without proven risk factors, stratifying the analyses on IDU. Impact of immunodeficiency, HAART, protease inhibitors, indinavir, didanosin, tenofovir and abacavir on risk of CVEs was analyzed using time-dependent Cox regression analyses. RESULTS HIV-infected individuals had an increased risk of CVEs compared with the comparison cohorts [(non-IDU HIV adjusted IRR 1.60; 95% confidence interval [CI] 1.32-1.94), (IDU HIV adjusted IRR 3.94; 95% CI 2.16-7.16)]. The risk was increased with and without proven risk factors. A CD4 cell count of 200 cells/μl or less before the start of HAART and exposure to abacavir increased the risk of CVE [(adjusted IRR 2.26; 95% CI 1.05-4.86) and (adjusted IRR 1.66; 95% CI 1.03-2.68)]. Protease inhibitors, indinavir, didanosin, tenofovir and HAART in general had no impact. Risk of CVEs was only increased in the parents of IDU HIV-infected individuals. CONCLUSION HIV-infected individuals have an increased risk of CVEs with and without proven risk factors. The risk is associated with IDU, low CD4 cell count and exposure to abacavir, but not with HAART. An association with family-related risk factors seems vague except for parents of IDU individuals.
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Cacciapuoti F. Some considerations about the hypercoagulable states and their treatments. Blood Coagul Fibrinolysis 2011; 22:155-9. [PMID: 21346557 DOI: 10.1097/mbc.0b013e3283436401] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ng KWP, Loh PK, Sharma VK. Role of investigating thrombophilic disorders in young stroke. Stroke Res Treat 2011; 2011:670138. [PMID: 21331344 PMCID: PMC3038796 DOI: 10.4061/2011/670138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 12/22/2010] [Accepted: 01/05/2011] [Indexed: 11/20/2022] Open
Abstract
Our knowledge about various inherited and acquired causes of thrombophilic disorders has increased significantly during the past decade. Technology for various diagnostic tests for these rare disorders has matched the rapid advances in our understanding about the thrombophilic disorders. Inherited thrombophilic disorders predispose young patients for various venous or arterial thrombotic and thromboembolic episodes. Our understanding has also improved about various gene-gene and gene-environment interactions and their impact on the resultant heterogenous clinical manifestations. We describe various thrombophilic disorders, their diagnostic tests, pathogenic potential in isolation or with other concurrent inherited/acquired defects and possible therapeutic and prophylactic strategies. Better understanding, optimal diagnostic and screening protocols are expected to improve the diagnostic yield and help to reduce morbidity, disability, and mortality in relatively younger patients harbouring these inherited and acquired thrombophilic disorders.
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Affiliation(s)
- Kay W P Ng
- Division of Neurology, Department of Medicine, National University Hospital, 1E, Kent Ridge Road, Singapore 119228
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Lee SB, Yun YJ, Kim JY. Central Retinal Artery Obstruction in Protein S Deficiency. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.12.2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sung Bok Lee
- Department of Ophthalmology, College of Medicine, Chungnam National Univercity, Deajeon, Korea
- Chungnam National University, Research Institute for Medical Sciences, Deajeon, Korea
| | - Yong Jun Yun
- Department of Ophthalmology, College of Medicine, Chungnam National Univercity, Deajeon, Korea
| | - Jung Yeul Kim
- Department of Ophthalmology, College of Medicine, Chungnam National Univercity, Deajeon, Korea
- Chungnam National University, Research Institute for Medical Sciences, Deajeon, Korea
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