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Vítor J, Bonifácio GV, Fonseca AC. Diagnosis of atrial fibrillation in young patients with ischemic stroke: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107299. [PMID: 37657400 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/21/2023] [Accepted: 08/05/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION The recommended cardiac rhythm evaluation to determine the etiology of ischemic stroke (IS) is similar in all patients regardless of their age and includes an electrocardiogram and at least a 24-hour heart rhythm monitoring. However, it is known that the main causes of IS vary according to patients' age. There is a higher preponderance of arterial dissections and patent foramen ovale in younger patients, while atrial fibrillation (AF) is more common in older patients. AIMS To determine the proportion of AF in young IS reported in the literature and determine if young IS patients found to have AF had known structural cardiac pathology. METHODS Systematic review of the literature searching PubMed and Embase for articles published since their inception to August 2020. Inclusion criteria were studies including at least 10 patients, aged 14-50 years-old, clinical or radiological diagnosis of IS and quantification of patients found to have AF. We conducted a meta-analysis using a random-effects model and calculated pooled proportions with 95% confidence intervals. RESULTS 8331 articles were screened, 154 were selected for full-text review. 43 studies were included in our final analysis (902800 patients). The proportion of AF in young IS overall was 3.1% [95%CI 2.4-3.7], I2 93.88%. Sub-analysis revealed a proportion of AF of 3.8% [95% CI 0.3-7.3] in lower-middle-income economies, versus 5.4% [95% CI 3-7.9] in upper-middle-income economies, and 2.2% [95% CI 1.6-2.8] in high-income economies. Only 3 studies mentioned the proportion of patients with AF that had structural cardiac pathology. CONCLUSION The proportion of AF in young IS was low. More studies are needed to better understand if young IS patients diagnosed with AF had a priori known structural cardiac pathology that could increase the probability of finding AF. This could lead to a reevaluation of the need for 24 hours cardiac rhythm evaluation in young patients without cardiac pathology.
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Affiliation(s)
- Joana Vítor
- Neurology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | | | - Ana Catarina Fonseca
- Stroke Unit, Neurology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa 1640-035, Portugal; Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Portugal; Instituto de Medicina Molecular, Lisboa, Portugal.
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge on epidemiology, risk factors and causes, diagnostic considerations, management, and prognosis of ischemic stroke in young adults (those 55 years old and younger). RECENT FINDINGS The incidence of ischemic stroke in young adults has been increasing since the 1980s, which has occurred in parallel with increasing prevalence of vascular risk factors and substance abuse among the younger population. Young adults have a considerably wider range of risk factors than older patients, including age-specific factors such as pregnancy/puerperium and oral contraceptive use. Behavioral risk factors such as low physical activity, excess alcohol consumption, and smoking are factors as well. More than 150 identified causes of early-onset ischemic stroke exist, including rare monogenic disorders. Several recent advances have been made in diagnosis and management of stroke in young adults, including molecular characterization of monogenic vasculitis due to deficiency of adenosine deaminase 2 and transcatheter closure of patent foramen ovale for secondary prevention. Compared with the background population of the same age and sex, long-term mortality in patients remains fourfold higher with cardiovascular causes underlying most of the deaths. The cumulative rate of recurrent stroke extends up to 15% at 10 years. Patients with atherosclerosis, high-risk sources of cardioembolism, and small vessel disease underlying their stroke seem to have the worst prognosis regarding survival and recurrent vascular events. Young stroke survivors also often have other adverse outcomes in the long term, including epilepsy, pain, cognitive problems, and depression. SUMMARY Systematic identification of risk factors and causes and the motivation of patients for long-term prevention and lifestyle changes are of utmost importance to improve the prognosis of early-onset ischemic stroke.
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Santos JV, Pereira J, Pinto R, Castro PM, Azevedo E, Freitas A. Atrial Fibrillation as an Ischemic Stroke Clinical and Economic Burden Modifier: A 15-Year Nationwide Study. Value Health 2017; 20:1083-1091. [PMID: 28964440 DOI: 10.1016/j.jval.2017.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 03/02/2017] [Accepted: 04/20/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS). Patients with AF may undergo preventive therapy. Although the AF impact in the clinical burden of IS has been studied, information is lacking in Southern Europe and there are no studies about the impact in potential years of life lost. Moreover, no nationwide or long-term study analyzed the economic burden of IS stratified by AF. OBJECTIVE To study the impact of AF in the clinical and economic burden of IS. METHODS We conducted a retrospective study using nationwide administrative data for all public hospitalizations in mainland Portugal from 2000 to 2014. We considered IS hospitalizations stratified by the presence of AF as secondary diagnosis. RESULTS Of the total 275,173 IS hospitalizations, 22.6% reported AF. The total number of IS hospitalizations increased from 14,836 in 2000 to 19,561 in 2014 (32% increase), with an increase of 138% in the AF group (from 2,411 to 5,727). In-hospital mortality decreased from 13.6% to 11.5% and was consistently higher in the AF group (17.3% vs. 11.1%). Mean charges were also higher in the AF group (€2297 vs. €2191). Age-adjusted potential years of life lost rate was higher in the group without AF (39.6 vs. 7.5). CONCLUSIONS AF-associated IS hospitalizations more than doubled in the studied 15-year period. Also, AF was responsible for higher in-hospital mortality and hospitalization charges. These facts highlight the need for early detection of AF and preventive treatment to limit IS occurrence, its associated burden, and poorer health outcomes.
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Affiliation(s)
- João Vasco Santos
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal;; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.
| | - João Pereira
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Roberto Pinto
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Miguel Castro
- Faculty of Medicine, Department of Clinical Neurosciences and Mental Health, University of Porto, Porto, Portugal; Faculty of Medicine, Cardiovascular Research and Development Unit, University of Porto, Porto, Portugal
| | - Elsa Azevedo
- Faculty of Medicine, Department of Clinical Neurosciences and Mental Health, University of Porto, Porto, Portugal; Faculty of Medicine, Cardiovascular Research and Development Unit, University of Porto, Porto, Portugal
| | - Alberto Freitas
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal;; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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Demeestere J, Fieuws S, Lansberg MG, Lemmens R. Detection of Atrial Fibrillation Among Patients With Stroke Due to Large or Small Vessel Disease: A Meta-Analysis. J Am Heart Assoc 2016; 5:JAHA.116.004151. [PMID: 27671319 PMCID: PMC5079054 DOI: 10.1161/jaha.116.004151] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Recent trials have demonstrated that extended cardiac monitoring increases the yield of paroxysmal atrial fibrillation (AF) detection in patients with cryptogenic stroke. The utility of extended cardiac monitoring is uncertain among patients with stroke caused by small and large vessel disease. We conducted a meta‐analysis to estimate the yield of AF detection in this population. Methods and Results We searched PubMed, Cochrane, and SCOPUS databases for studies on AF detection in stroke patients and excluded studies restricted to patients with cryptogenic stroke or transient ischemic attack. We abstracted AF detection rates for 3 populations grouped by stroke etiology: large vessel stroke, small vessel stroke, and stroke of undefined etiology (a mixture of cryptogenic, small vessel, large vessel, and other stroke etiologies). Our search yielded 30 studies (n=5687). AF detection rates were similar in patients with large vessel (2.2%, 95% CI 0.3–5.5; n=830) and small vessel stroke (2.4%, 95% CI 0.4–6.1; n=520). No studies had a monitoring duration longer than 7 days. The yield of AF detection in the undefined stroke population was higher (9.2%; 95% CI 7.1–11.5) compared to small vessel stroke (P=0.02) and large vessel stroke (P=0.02) populations. Conclusions AF detection rate is similar in patients with small and large vessel strokes (2.2–2.4%). Because no studies reported on extended monitoring (>7 days) in these stroke populations, we could not estimate the yield of AF detection with long‐term cardiac monitoring. Randomized controlled trials are needed to examine the utility of AF detection with long‐term cardiac monitoring (>7 days) in this patient population.
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Affiliation(s)
- Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversitary Institute for Biostatistics and Statistical Bio-information, KU Leuven-University of Leuven & Universiteit Hasselt, Leuven, Belgium
| | | | - Robin Lemmens
- KU Leuven-University of Leuven, Department of Neurosciences Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), Leuven, Belgium VIB, Vesalius Research Center Laboratory of Neurobiology, Leuven, Belgium University Hospitals Leuven, Department of Neurology, Leuven, Belgium
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Putaala J. Ischemic stroke in the young: Current perspectives on incidence, risk factors, and cardiovascular prognosis. Eur Stroke J 2016; 1:28-40. [PMID: 31008265 DOI: 10.1177/2396987316629860] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/06/2016] [Indexed: 12/25/2022] Open
Abstract
About one-fourth of ischemic strokes occur in working-aged individuals in the high-income countries, with worldwide increasing incidence in this age group from 1980s to present. Recent evidence suggests that traditional vascular risk factors are more prevalent than previously suggested in young adult stroke patients and they accumulate with age particularly in men. Accordingly, relatively high rates of atherosclerotic changes have been detected in these patients. The strength of association of vascular risk factors has gone poorly studied, however. Many young patients with ischemic stroke have, in turn, no traditional risk factors, while they may harbor other conditions with weak or uncertain association with the stroke alone. These individual conditions often represent a risk factor that may be strictly young-age specific, more prevalent in younger than older stroke patients (e.g. patent foramen ovale), or more prevalent among the young in the population. Despite high rates of vascular risk factors and atherosclerotic changes, these findings do not translate to higher frequencies of identified classical stroke mechanisms. In fact, cryptogenic causes are markedly common and even more frequent among the very young patients. Limited randomized trial evidence exists to support secondary prevention decision-making in patients, yet they face an increased risk of death and future vascular events for years to come-dependent on risk factor profile and cause of the stroke. This review provides an overview of recent data on epidemiology, risk factors, and their strength of association in ischemic stroke in the young. Furthermore, the relationship between with the risk factors and cardiovascular outcomes and key features on the evidence related to secondary prevention will be discussed.
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Affiliation(s)
- Jukka Putaala
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
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Prefasi D, Martínez-sánchez P, Fuentes B, Díez-tejedor E. Severity and outcomes according to stroke etiology in patients under 50 years of age with ischemic stroke. J Thromb Thrombolysis 2016; 42:272-82. [DOI: 10.1007/s11239-016-1336-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sanak D, Hutyra M, Kral M, Bartkova A, Zapletalova J, Fedorco M, Veverka T, Vindis D, Dornak T, Skala T, Skoloudik D, Taborsky M, Kanovsky P. Paroxysmal atrial fibrillation in young cryptogenic ischemic stroke: A 3-week ECG Holter monitoring study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015; 159:283-7. [PMID: 25916280 DOI: 10.5507/bp.2015.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/14/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation is known very frequent cause of ischemic stroke. Undetected paroxysmal atrial fibrillation (PAF) is thus often considered a possible cause of cryptogenic ischemic stroke (CIS). The aim of this prospective study was to detect PAF using ECG Holter monitoring and determinate whether prolongation of the Holter monitoring to 3 weeks would increase the detection rates of PAF in young CIS patients ≤ 50 years. METHODS The study set consisted of IS patients ≤ 50 years enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study (NCT01541163). CIS was defined according to the TOAST criteria including the absence of ultrasonographic or angiographic signs of atherosclerosis, vasculitis or dissection. Admission ECG, serum levels of high sensitive Troponin T (hs TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP), markers of thrombophilia, transoesophageal echocardiography (TEE) and 24-hour ECG-Holter monitoring were performed in all patients. In case of negative 24-h ECG Holter, an additional 3-weeks monitoring was done. RESULTS Of the 105 enrolled patients ≤ 50 years, 95 (90%) were identified as cryptogenic (49 males, mean age 39.1 ± 8.2 years). All CIS patients had normal admission ECG. In total, PAF was detected in 9 (9.5%, 95% CI: 3.5% - 17.8%) patients; in two during 24-h ECG Holter and in seven during 3-weeks Holter monitoring. Patients with PAF had more frequently elevated admission hs TnT and NT-proBNP levels (P - 0.0001). CONCLUSIONS PAF was detected in 9.5% of young CIS patients and 3-weeks ECG Holter monitoring increased the detection rate.
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Affiliation(s)
- Daniel Sanak
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Cardiology, University Hospital Olomouc
| | - Michal Kral
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - Andrea Bartkova
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc
| | | | - Tomas Veverka
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - David Vindis
- Department of Cardiology, University Hospital Olomouc
| | - Tomas Dornak
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
| | - Tomas Skala
- Department of Cardiology, University Hospital Olomouc
| | - David Skoloudik
- Department of Nursing, Faculty of Health Sciences, Palacky University Olomouc
| | | | - Petr Kanovsky
- Comprehensive Stroke Center, Department of Neurology, University Hospital Olomouc, Czech Republic
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Šaňák D, Hutyra M, Král M, Bártková A, Zapletalová J, Fedorco M, Veverka T, Vindiš D, Dorňák T, Skála T, Školoudík D, Táborský M, Kaňovský P. Atrial Fibrillation in Young Ischemic Stroke Patients: An Underestimated Cause? Eur Neurol 2015; 73:158-63. [DOI: 10.1159/000369793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 11/09/2014] [Indexed: 11/19/2022]
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Affiliation(s)
- A H V Schapira
- Department of Clinical Neurosciences, UCL Institute of Neurology, London, UK.
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Ward F, McGovern R, Cotter PE. Troponin-I is a predictor of a delayed diagnosis of atrial fibrillation in acute ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis 2014; 24:66-72. [PMID: 25440352 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/28/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. METHODS Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. RESULTS A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). CONCLUSIONS TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.
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Affiliation(s)
- Frank Ward
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland.
| | - Rory McGovern
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
| | - Paul E Cotter
- Department of Geriatric and Stroke Medicine, St Luke's Hospital, Kilkenny, Ireland
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Arevalo-Manso JJ, Martínez-Sánchez P, Fuentes B, Ruiz-Ares G, Sanz-Cuesta BE, Prefasi D, Juarez-Martin B, Navarro-Parias A, Parrilla-Novo P, Diez-Tejedor E. Can we improve the early detection of atrial fibrillation in a stroke unit? Detection rate of a monitor with integrated detection software. Eur J Cardiovasc Nurs 2014; 15:64-71. [PMID: 25230856 DOI: 10.1177/1474515114552043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 08/29/2014] [Indexed: 11/17/2022]
Abstract
INTRODUCTION It is unknown whether monitors that include atrial fibrillation recognition software (AF-RS) increase the rate of early atrial fibrillation (AF) detection in acute stroke. We aimed to evaluate the AF detection rate of an AF-RS monitor and compare it with standard monitoring. METHODS This was a retrospective, single-centre observational study conducted on consecutive patients with acute transient ischaemic attack or brain infarction attended in a stroke unit (SU) with six beds. Five beds had a standard monitor with a three-lead electrocardiogram (ECG)-tracing monitor that did not automatically detect AF, and one bed had a 12-lead ECG monitor with integrated AF-RS. All patients were monitored for at least 24 h and underwent a daily ECG during their stay in the SU. In case of unknown stroke aetiology, the patients underwent 24 h Holter monitoring. RESULTS A total of 76 patients were included: 59 patients in the standard monitor group and 17 patients in the AF-RS monitor group. The mean age was 72.11 (±13.09) years, and 59.2% were men. A total of 20 new cases of AF were identified. The AF-RS monitor showed a higher rate of AF detection than the standard devices (57.1% vs 7.7%, p=0.031). The AF-RS monitor showed sensitivity, specificity, positive predictive value, and negative predictive values of 57.1%, 100%, 100% and 76.9%, respectively. For the standard monitors, these values were 7.7%, 100%, 100% and 79.3%, respectively. CONCLUSION The monitor with AF-RS demonstrated a higher detection rate for AF than standard ECG monitoring in acute stroke patients in a SU.
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Affiliation(s)
- Juan Jose Arevalo-Manso
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Patricia Martínez-Sánchez
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Blanca Fuentes
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Gerardo Ruiz-Ares
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Borja Enrique Sanz-Cuesta
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Daniel Prefasi
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Belén Juarez-Martin
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Azahara Navarro-Parias
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Pilar Parrilla-Novo
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
| | - Exuperio Diez-Tejedor
- Department of Neurology and Stroke Centre, La Paz University Hospital; IdiPAZ, Hospital La Paz Institute for Health Research; Autonomous University of Madrid, Spain
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