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Lozano-Tovar S, Cremascoli R, Nuccetelli M, Sancesario G, Cattaldo S, Prina E, Verde F, Cappelli S, Bernardini S, Mercuri NB, Liguori C. Cerebrospinal-fluid Orexin-A levels in different neurocognitive disorders: a comparison study. Neurol Sci 2025:10.1007/s10072-025-08148-0. [PMID: 40198471 DOI: 10.1007/s10072-025-08148-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Accepted: 03/23/2025] [Indexed: 04/10/2025]
Abstract
In the present study, we investigated the differences in cerebrospinal fluid (CSF) orexin-A levels among patients with different neurocognitive disorders, such as mild or moderate to severe Alzheimer's disease (AD; mAD, msAD, respectively), behavioral variants of frontotemporal dementia (bv-FTD), non-fluent primary aphasia (NFPA), and idiopathic normal pressure hydrocephalus (iNPH). A total of 214 participants were evaluated (mAD, 45; msAD, 31; bv-FTD, 12; NFPA, 22; iNPH, 13; non-demented elderly controls, 91). The highest CSF orexin-A levels were found in iNPH patients (263.31 ± 56.89 pg/mL). Patients affected by NFPA (210.86 ± 61.99 pg/mL), iNPH, and msAD (173.04 ± 19.76 pg/mL) showed higher CSF orexin-A concentrations than controls (145.18 ± 27.01pg/mL) (p < 0.001). Bv-FTD (190.12 ± 100.84 pg/mL) and mAD (130.76 ± 21.70 pg/mL) patients showed no significant differences in CSF orexin-A levels compared with controls. mAD patients showed also lower CSF orexin-A concentrations than all other patient groups.In conclusion, orexin-A presents different CSF levels among neurocognitive disorders. The mechanisms underlying this difference vary and may include sleep-wake cycle impairment, behavioral disturbances, and CSF dynamics. The development of drugs that antagonize the orexin system could open a new frontier of research linking orexin neurotransmission to neurocognitive disorders.
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Affiliation(s)
- Susana Lozano-Tovar
- Facultad de Psicología, Universidad Nacional Autónoma de México (UNAM), Circuito Ciudad Universitaria Avenida, C.U, Mexico City, 04510, Mexico
| | - Riccardo Cremascoli
- Unit of Neurology and Neurorehabilitation, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, 28824, Verbania, Italy
| | - Marzia Nuccetelli
- Department of Clinical Biochemistry and Molecular Biology, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Sancesario
- Department of Systems Medicine, University of Rome Tor Vergata, 00133, Rome, Italy
| | - Stefania Cattaldo
- Laboratory of Clinical Neurobiology, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, 28824, Verbania, Italy
| | - Elisa Prina
- Department of Neurology and Laboratory of Neuroscience, IRCCS, Istituto Auxologico Italiano, Milan, Italy
| | - Federico Verde
- Department of Neurology and Laboratory of Neuroscience, IRCCS, Istituto Auxologico Italiano, Milan, Italy
- Department of Pathophysiology and Transplantation, "Dino Ferrari" Center, Università degli Studi di Milano, Milan, Italy
| | - Simone Cappelli
- Laboratory of Psychology, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, 28824, Verbania, Italy
| | - Sergio Bernardini
- Unit of Neurology and Neurorehabilitation, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, 28824, Verbania, Italy
| | - Nicola Biagio Mercuri
- Department of Systems Medicine, University of Rome Tor Vergata, 00133, Rome, Italy
- Sleep Medicine Centre, Neurology Unit, University Hospital of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Claudio Liguori
- Department of Systems Medicine, University of Rome Tor Vergata, 00133, Rome, Italy.
- Sleep Medicine Centre, Neurology Unit, University Hospital of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
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Lidén S, Lindam A, Farahmand D, Landtblom A, Laurell K. Decrease of excessive daytime sleepiness after shunt treatment for normal pressure hydrocephalus. J Sleep Res 2025; 34:e14333. [PMID: 39275945 PMCID: PMC11911039 DOI: 10.1111/jsr.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/13/2024] [Accepted: 08/26/2024] [Indexed: 09/16/2024]
Abstract
Sleepiness and apathy are often reported in patients with normal pressure hydrocephalus. However, research on outcomes after shunt surgery has mainly focused on the classical triad symptoms, that is, gait, cognition, and bladder dysfunction. This study aimed to describe the effects of shunt treatment on excessive daytime sleepiness and whether there was a relation to changes in ventricular volume. Pre- and postsurgical excessive daytime sleepiness was investigated using the Epworth sleepiness scale in a sample of 32 patients with normal pressure hydrocephalus who underwent shunt surgery. Data were gathered before surgery and at 1, 2, and 3 months after surgery and with different settings of the shunt. In the total sample, the Epworth sleepiness scale improved by a median of 1.5 points at 1 month after surgery, p = 0.026. The improvement was predominately found in the group (n = 6) with high presurgical daytime sleepiness (Epworth sleepiness scale >12) (median = 12 points, p = 0.035) compared with a median change of 0 points (p = 0.47) in the group with Epworth sleepiness scale ≤12 (n = 26). Between the postsurgical follow-ups, no further change in the Epworth sleepiness scale score was observed. The Epworth sleepiness scale score did not correlate with clinical tests nor with ventricular volume. Daytime sleepiness seems to be another domain of normal pressure hydrocephalus symptomatology in addition to the classical triad that is responsive to treatment, at least when pronounced. The Epworth sleepiness scale is a quick test to administer and could be a valuable addition to pre-surgical screening for treatable symptoms.
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Affiliation(s)
- Simon Lidén
- Department of Biomedical and Clinical Sciences, NeurologyLinköping UniversityLinköpingSweden
| | - Anna Lindam
- Department of Public Health and Clinical Medicine, Unit of Research, Education and Development – ÖstersundUmeå UniversityUmeåSweden
| | - Dan Farahmand
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Anne‐Marie Landtblom
- Department of Biomedical and Clinical Sciences, NeurologyLinköping UniversityLinköpingSweden
- Department of Medical Sciences, NeurologyUppsala UniversityUppsalaSweden
| | - Katarina Laurell
- Department of Biomedical and Clinical Sciences, NeurologyLinköping UniversityLinköpingSweden
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Riedel CS. In response to Mutti et al. 2024 commentary on "Transient intracranial pressure elevations (B waves) associated with sleep apnea: the neglected role of cyclic alternating pattern". Fluids Barriers CNS 2024; 21:105. [PMID: 39702226 DOI: 10.1186/s12987-024-00610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 12/11/2024] [Indexed: 12/21/2024] Open
Abstract
The physiology of transient intracranial pressure (ICP) elevations (B waves), remains incompletely understood and appears to involve multiple mechanisms, including obstructive sleep apnea (OSA). Transient ICP elevations are associated with OSA and cyclic alternating pattern (CAP) metrics, suggesting a complex interplay between sleep fragmentation and ICP dynamics. Additionally, CAP metrics could complement standard OSA assessments, providing deeper insights into transient ICP fluctuations, particularly in conditions like normal-pressure hydrocephalus and idiopathic intracranial hypertension. Future studies should explore CAP-ICP interactions to elucidate their physiological and clinical implications.
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Affiliation(s)
- Casper Schwartz Riedel
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark.
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Regalbuto S, Zangaglia R, Valentino F, Todisco M, Pacchetti C, Cotta Ramusino M, Mazzacane F, Picascia M, Arceri S, Malomo G, Capriglia E, Spelta L, Rubino A, Pisani A, Terzaghi M. Clinical correlates of obstructive sleep apnoea in idiopathic normal pressure hydrocephalus. Eur J Neurol 2024; 31:e16448. [PMID: 39207116 PMCID: PMC11555027 DOI: 10.1111/ene.16448] [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: 05/28/2024] [Revised: 07/30/2024] [Accepted: 08/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND PURPOSE The pathogenesis of idiopathic normal pressure hydrocephalus (iNPH) remains controversial. Limited studies have indicated a high prevalence of obstructive sleep apnoea (OSA) amongst iNPH patients. The aim was to investigate the clinical correlates of OSA in iNPH patients. METHODS In this cross-sectional observational study, consecutive iNPH patients were prospectively enrolled. Evaluations included the iNPH Rating Scale, the Movement Disorder Society Unified Parkinson's Disease Rating Scale part III, the time and number of steps to walk 10 m, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, a complete neuropsychological evaluation, 3-T brain MRI, full-night video-polysomnography, tap test and cerebrospinal fluid (CSF) neurodegeneration biomarkers. RESULTS Fifty-one patients were screened, of whom 38 met the inclusion criteria. Amongst the recruited patients, 19/38 (50%) exhibited OSA, with 12/19 (63.2%) presenting moderate to severe disorder. OSA+ iNPH patients required more time (p = 0.02) and more steps (p = 0.04) to complete the 10-m walking test, had lower scores on the gait subitem of the iNPH Rating Scale (p = 0.04) and demonstrated poorer performance on specific neuropsychological tests (Rey Auditory Verbal Learning Test immediate recall, p = 0.03, and Rey-Osterrieth Complex Figure, p = 0.01). Additionally, OSA+ iNPH patients had higher levels of total tau (p = 0.02) and phospho-tau (p = 0.03) in their CSF but no statistically significant differences in beta-amyloid (1-42) levels compared to OSA- iNPH patients. CONCLUSION Obstructive sleep apnoea is highly prevalent in iNPH patients, particularly at moderate to severe levels. OSA is associated with worse motor and cognitive performance in iNPH. The CSF neurodegeneration biomarker profile observed in OSA+ iNPH patients may reflect OSA-induced impairment of cerebral fluid dynamics.
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Affiliation(s)
- Simone Regalbuto
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
| | | | | | | | | | - Matteo Cotta Ramusino
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
| | - Federico Mazzacane
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
| | - Marta Picascia
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
| | | | - Gaetano Malomo
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
| | - Elena Capriglia
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
| | - Laura Spelta
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
| | - Annalisa Rubino
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
| | - Antonio Pisani
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
| | - Michele Terzaghi
- IRCCS Mondino FoundationNational Neurological InstitutePaviaItaly
- Department of Brain and Behavioural SciencesUniversity of PaviaPaviaItaly
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Riedel CS, Martinez-Tejada I, Andresen M, Wilhjelm JE, Jennum P, Juhler M. Transient intracranial pressure elevations (B waves) are associated with sleep apnea. Fluids Barriers CNS 2023; 20:69. [PMID: 37784168 PMCID: PMC10544378 DOI: 10.1186/s12987-023-00469-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Repetitive transient intracranial pressure waveform elevations up to 50 mmHg (ICP B-waves) are often used to define pathological conditions and determine indications for ICP-reducing treatment. We recently showed that nocturnal transient ICP elevations are present in patients without structural brain lesions or hydrocephalus in whom they are associated with sleep apnea. However, whether this signifies a general association between ICP macropatterns and sleep apnea remains unknown. METHODS We included 34 patients with hydrocephalus, or idiopathic intracranial hypertension (IIH), who were referred to the Neurosurgical Department, Copenhagen, Denmark, from 2017 to 2021. Every patient underwent diagnostic overnight ICP monitoring for clinical indications, with simultaneous polysomnography (PSG) sleep studies. All transient ICP elevations were objectively quantified in all patients. Three patients were monitored with continuous positive airway pressure (CPAP) treatment for an additional night. RESULTS All patients had transient ICP elevations associated with sleep apnea. The mean temporal delay from sleep apnea to transient ICP elevations for all patients was 3.6 s (SEM 0.2 s). Ramp-type transient ICP elevations with a large increase in ICP were associated with rapid eye movement (REM) sleep and sinusoidal-type elevations with non-REM (NREM) sleep. In three patients treated with CPAP, the treatment reduced the number of transient ICP elevations with a mean of 37%. CPAP treatment resulted in insignificant changes in the average ICP in two patients but elevated the average ICP during sleep in one patient by 5.6 mmHg. CONCLUSION The findings suggest that sleep apnea causes a significant proportion of transient ICP elevations, such as B-waves, and sleep apnea should be considered in ICP evaluation. Treatment of sleep apnea with CPAP can reduce the occurrence of transient ICP elevations. More research is needed on the impact of slow oscillating mechanisms on transient ICP elevations during high ICP and REM sleep.
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Affiliation(s)
- Casper Schwartz Riedel
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, Copenhagen East, 2100, Copenhagen, Denmark.
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark.
| | - Isabel Martinez-Tejada
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, Copenhagen East, 2100, Copenhagen, Denmark
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Morten Andresen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, Copenhagen East, 2100, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Copenhagen University Hospital, Rigshospitalet, Glostrup, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 6, Copenhagen East, 2100, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Yamada S, Ito H, Tanikawa M, Ii S, Otani T, Wada S, Oshima M, Watanabe Y, Mase M. Age-Related Changes in Cerebrospinal Fluid Dynamics in the Pathogenesis of Chronic Hydrocephalus in Adults. World Neurosurg 2023; 178:351-358. [PMID: 37516143 DOI: 10.1016/j.wneu.2023.07.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023]
Abstract
Cerebrospinal fluid (CSF) dynamics has dramatically changed in this century. In the latest concept of CSF dynamics, CSF is thought to be produced mainly from interstitial fluid excreted from the brain parenchyma and is absorbed in the meningeal lymphatics. Moreover, CSF does not always flow from the ventricles to the subarachnoid space unidirectionally through the foramina of Magendie and Luschka. In an environment of increased intracranial CSF in idiopathic normal pressure hydrocephalus, CSF freely moves through the inferior choroidal point of the choroidal fissure, which interfaces between the inferior horn of the lateral ventricles and the ambient cistern and through the velum interpositum between the third ventricle and the quadrigeminal cistern. The structure of the hippocampus adjacent to the inferior part of the choroidal fissure may be important in preventing the accumulation of waste products in the hippocampus. A recent imaging technology for CSF dynamics, such as four-dimensional flow and intravoxel incoherent motion magnetic resonance imaging, can visualize and quantify the pulsatile complex CSF motion in clinical usage. We present the current concepts of CSF dynamics with advanced magnetic resonance imaging techniques, which will be helpful in the management and understanding of the pathogenesis of chronic hydrocephalus in adults.
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Affiliation(s)
- Shigeki Yamada
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Aichi, Japan; Interfaculty Initiative in Information Studies/Institute of Industrial Science, The University of Tokyo, Tokyo, Japan; Normal Pressure Hydrocephalus Center, Rakuwakai Otowa Hospital, Kyoto, Japan.
| | - Hirotaka Ito
- Medical System Research & Development Center, FUJIFILM Corporation, Tokyo, Japan
| | - Motoki Tanikawa
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Aichi, Japan
| | - Satoshi Ii
- Faculty of System Design, Tokyo Metropolitan University, Tokyo, Japan
| | - Tomohiro Otani
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Osaka, Japan
| | - Shigeo Wada
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Osaka, Japan
| | - Marie Oshima
- Interfaculty Initiative in Information Studies/Institute of Industrial Science, The University of Tokyo, Tokyo, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Shiga, Japan
| | - Mitsuhito Mase
- Department of Neurosurgery, Nagoya City University Graduate School of Medical Science, Aichi, Japan
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Rydja J, Kollén L, Ulander M, Tullberg M, Lundin F. Physical Capacity and Activity in Patients With Idiopathic Normal Pressure Hydrocephalus. Front Neurol 2022; 13:845976. [PMID: 35418936 PMCID: PMC8996117 DOI: 10.3389/fneur.2022.845976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/28/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Most patients with idiopathic normal pressure hydrocephalus (iNPH) improve gait after surgery. However, knowledge on physical capacity and activity after shunt surgery is limited. One of the aims of this study was to evaluate the effect of shunt surgery in patients with iNPH on short-distance walking, functional exercise capacity, functional strength, and variables of activity and sleep, 3 and 6 months postoperatively. Another aim was to evaluate the effect of a physical exercise program. Additionally, we studied how changes in short-distance walking were correlated with functional exercise capacity and voluntary walking. Methods In total, 127 patients were consecutively included and randomized to the exercise group (n = 62) or the control group (n = 65). Participants in the exercise group underwent the supervision of a 12-week exercise program. All patients were assessed before surgery, at 3 and 6 months postoperatively with the 10-m walk test (10MWT), the 6-min walk test (6MWT), 30-s chair stand test (30sCST), and with the actigraphic recordings of activity variables measured for a total of 24 h/day for at least 3 days. Results All patients improved at 3 months postoperatively in the 10MWT (p < 0.001), 6MWT (p < 0.001), and 30sCST (p < 0.001). These results were maintained after 6 months. Actigraphic recordings for voluntary walking (steps per minute) were improved and nighttime sleep (%) increased after 6 months (p = 0.01, p = 0.04). There were no significant differences between the exercise group and the control group, except for the postoperative change in the proportion of daytime sleep after 3 months, which was slightly more reduced compared to baseline in the exercise group (p = 0.04). Changes after 3 months in the 10MWT and 6MWT were moderately correlated (ρ= −0.49, p = 0.01) whereas the correlation between the 10MWT and voluntary walking was weak (ρ = −0.34, p = 0.01). Conclusion Shunt surgery improved short-distance walking, functional exercise capacity, functional strength, and voluntary walking. An exercise program did not affect these outcomes. Short-distance walking was weakly correlated with voluntary walking, indicating improved physical capacity does not directly translate to increased physical activity. Further research should address how interventions should be tailored to promote physical activity after shunt surgery. Trial Registration clinicaltrials.gov, Id: NCT02659111.
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Affiliation(s)
- Johanna Rydja
- Department of Activity and Health and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lena Kollén
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Ulander
- Department of Clinical Neurophysiology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Mats Tullberg
- Department of Clinical Neuroscience, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Lundin
- Department of Neurology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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