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Ismail A, Ravipati S, Gonzalez-Hernandez D, Mahmood H, Imran A, Munoz EJ, Naeem S, Abdin ZU, Siddiqui HF. Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 2023; 15:e38794. [PMID: 37303351 PMCID: PMC10250083 DOI: 10.7759/cureus.38794] [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] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.
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Affiliation(s)
- Aqsa Ismail
- Department of Medicine, United Medical and Dental College, Karachi, PAK
| | - Shivani Ravipati
- Department of Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | | | - Hashim Mahmood
- Department of Medicine, University College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Alizay Imran
- Department of Surgery, Windsor University School of Medicine, Chicago, USA
| | - Eduardo J Munoz
- Department of General Medicine, Montemorelos University, Montemorelos, MEX
| | - Saad Naeem
- Department of Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
- Department of Internal Medicine, Punjab Social Security Hospital, Faisalabad, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Humza F Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Pacheco JA, Rasmussen LV, Wiley K, Person TN, Cronkite DJ, Sohn S, Murphy S, Gundelach JH, Gainer V, Castro VM, Liu C, Mentch F, Lingren T, Sundaresan AS, Eickelberg G, Willis V, Furmanchuk A, Patel R, Carrell DS, Deng Y, Walton N, Satterfield BA, Kullo IJ, Dikilitas O, Smith JC, Peterson JF, Shang N, Kiryluk K, Ni Y, Li Y, Nadkarni GN, Rosenthal EA, Walunas TL, Williams MS, Karlson EW, Linder JE, Luo Y, Weng C, Wei W. Evaluation of the portability of computable phenotypes with natural language processing in the eMERGE network. Sci Rep 2023; 13:1971. [PMID: 36737471 PMCID: PMC9898520 DOI: 10.1038/s41598-023-27481-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023] Open
Abstract
The electronic Medical Records and Genomics (eMERGE) Network assessed the feasibility of deploying portable phenotype rule-based algorithms with natural language processing (NLP) components added to improve performance of existing algorithms using electronic health records (EHRs). Based on scientific merit and predicted difficulty, eMERGE selected six existing phenotypes to enhance with NLP. We assessed performance, portability, and ease of use. We summarized lessons learned by: (1) challenges; (2) best practices to address challenges based on existing evidence and/or eMERGE experience; and (3) opportunities for future research. Adding NLP resulted in improved, or the same, precision and/or recall for all but one algorithm. Portability, phenotyping workflow/process, and technology were major themes. With NLP, development and validation took longer. Besides portability of NLP technology and algorithm replicability, factors to ensure success include privacy protection, technical infrastructure setup, intellectual property agreement, and efficient communication. Workflow improvements can improve communication and reduce implementation time. NLP performance varied mainly due to clinical document heterogeneity; therefore, we suggest using semi-structured notes, comprehensive documentation, and customization options. NLP portability is possible with improved phenotype algorithm performance, but careful planning and architecture of the algorithms is essential to support local customizations.
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Affiliation(s)
| | | | - Ken Wiley
- National Human Genome Research Institute, Bethesda, USA
| | | | - David J Cronkite
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | | | | | | | | | | | - Cong Liu
- Columbia University, New York, USA
| | - Frank Mentch
- Children's Hospital of Philadelphia, Philadelphia, USA
| | - Todd Lingren
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | | | | | | | | | - David S Carrell
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Yu Deng
- Northwestern University, Evanston, USA
| | | | | | | | | | | | | | | | | | - Yizhao Ni
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Yikuan Li
- Northwestern University, Evanston, USA
| | | | | | | | | | | | | | - Yuan Luo
- Northwestern University, Evanston, USA
| | | | - WeiQi Wei
- Vanderbilt University Medical Center, Nashville, USA
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Algahtani H, Shirah B, Alghamdi AS, Subahi A, Alqahtani SA, Alshamy A. Carotid Artery Angioplasty and Stenting for Carotid Stenosis: A Single-Center Experience from Saudi Arabia. Neurointervention 2020; 15:133-139. [PMID: 32894903 PMCID: PMC7608497 DOI: 10.5469/neuroint.2020.00052] [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: 02/24/2020] [Accepted: 08/17/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Atherosclerotic stenosis of the extracranial carotid artery accounts for approximately 20% of all strokes. Both carotid artery endarterectomy and carotid artery angioplasty with stenting (CAAS) are recommended for symptomatic patients with 50% or more stenosis or asymptomatic patients with 70% or more stenosis. CAAS is under-reported in Saudi Arabia, as evidenced by a thorough literature search. In this article, we aim to share our experience of CAAS to call for the necessity of conducting more research on stroke and emphasize the local need of utilizing more endovascular treatments like CAAS. Materials and Methods A retrospective single-center observational study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia. The inclusion criteria consisted of all adult patients (18 years and above) with carotid stenosis who were treated with CAAS. Results A total of 16 patients were included in the study. The mean age of the participants was 66.9±13.5 years (range 30–87 years). All patients were symptomatic (had a previous stroke or transient ischemic attack). The procedure was successful in 14 patients (87.5%), while it failed in 2 patients (12.5%) due to technical reasons. All patients had no stroke or myocardial infarction within 30 days of the procedure. Conclusion Despite the advancement in medicine with free healthcare services in Saudi Arabia, the interventional procedures for secondary prevention of strokes are underutilized. Collaboration between different hospitals will be extremely helpful since few centers in each city are providing such treatments by an expert neurointerventionist and/or strokologist. The good selection of candidates, optimal management of comorbid conditions, and multidisciplinary care may improve outcomes and reduce mortality.
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Affiliation(s)
- Hussein Algahtani
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Bader Shirah
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Abdullah S Alghamdi
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Ahmad Subahi
- King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | | | - Abdulrahman Alshamy
- King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Abstract
PURPOSE OF REVIEW Although primarily designed for medical documentation and billing purposes, the electronic health record (EHR) has significant potential for translational research. In this article, we provide an overview of the use of the EHR for genomics research with a focus on heritable lipid disorders. RECENT FINDINGS Linking the EHR to genomic data enables repurposing of vast phenotype data for genomic discovery. EHR data can be used to study the genetic basis of common and rare disorders, identify subphenotypes of diseases, assess pathogenicity of novel genomic variants, investigate pleiotropy, and rapidly assemble cohorts for genomic medicine clinical trials. EHR-based discovery can inform clinical practice; examples include use of polygenic risk scores for assessing disease risk and use of phenotype data to interpret rare variants. Despite limitations such as missing data, variable use of standards and poor interoperablility between disparate systems, the EHR is a powerful resource for genomic research. SUMMARY When linked to genomic data, the EHR can be leveraged for genomic discovery, which in turn can inform clinical care, exemplifying the virtuous cycle of a learning healthcare system.
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Affiliation(s)
- Maya S Safarova
- Atherosclerosis and Lipid Genomics Laboratory and Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Atkins PW, Perez HA, Spence JD, Muñoz SE, Armando LJ, García NH. Increased carotid plaque burden in patients with family medical history of premature cardiovascular events in the absence of classical risk factors. Arch Med Sci 2019; 15:1388-1396. [PMID: 31749866 PMCID: PMC6855146 DOI: 10.5114/aoms.2019.84677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/03/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The hypothesis that relates atherosclerosis to traditional risk factors (TRF) seems to be not as adequate as previously thought; other risk factors (RF) need to be considered to prevent atherosclerosis progression. Although a family medical history of premature cardiovascular events (FHx) has been considered the putative RF for decades, it has not been incorporated routinely into cardiovascular risk evaluation along with another RF. The objective of this study was to investigate whether FHx is associated with a higher atherosclerotic burden, measured as carotid total plaque area (TPA) in a population having no traditional RF. MATERIAL AND METHODS The study included 4,351 primary care patients in Argentina. After excluding a personal history of cardiovascular disease (CVD) and TRF: hypertension, diabetes mellitus, hypercholesterolemia, smoking history, and body mass index (BMI) > 25 kg/cm2, 34 patients with FHx were identified. Compared to 56 matched controls TPA was 86% higher in FHx patients (p < 0.05). A second analysis performed in hypertensive patients but no other TRF; 32 patients with FHx were identified. RESULTS Compared with 44 matched controls, TPA was 77% higher in FHx patients (p < 0.05). A final analysis using a generalized linear model with TPA progression as the response variable suggests that TPA progresses more rapidly in FHx patients compared to controls. CONCLUSIONS The FHx was associated with increased TPA burden and progression in the absence of other TRF. This supports ultrasound screening in FHx patients in order to detect high-risk patients who may benefit from early intervention.
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Affiliation(s)
- Paul W. Atkins
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - J. David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Sonia E. Muñoz
- Instituto de Investigaciones en Ciencias de la Salud FCM (INICSA-CONICET), Córdoba, Argentina
| | | | - Néstor H. García
- Instituto de Investigaciones en Ciencias de la Salud FCM (INICSA-CONICET), Córdoba, Argentina
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An D, Zhang J, Tang X, Gao P, Li Y, Wang Y, Zhu D. Association of ATP2B1 common variants with asymptomatic intracranial and extracranial large artery stenosis in hypertension patients. Clin Exp Hypertens 2018; 41:323-329. [PMID: 29902063 DOI: 10.1080/10641963.2018.1481421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS Genetic factors play an important role in the cervico-cerebral large-artery atherosclerotic stenosis (LAS), and ATP2B1 gene has been associated with the process of atherosclerosis disorders, such as coronary artery disease and arterial stiffness. But there is little information about the relationship between ATP2B1 gene and atherosclerosis in the intracranial arteries. We hereby investigated the association of common variants in ATP2B1 gene with LAS in asymptomatic Chinese hypertension patients. METHODS The stenosis of intracranial and extracranial arteries were evaluated in 899 subjects through computerized tomography angiography from the aortic arch to the skull base. A total of 11 ATP2B1 common variants were genotyped. Multivariate logistic regression was carried out in a dominant model with confounding factors adjusted. RESULTS rs17249754-A (OR = 0.43, p = 0.0002) and rs1401982-G (OR = 0.47, p = 0.0007) were associated with decreased susceptibility of concurrent extra and intracranial stenosis even after Bonferroni correction. These two minor alleles were also significantly associated with less stenotic arteries and moderate-to-severe stenosis. CONCLUSION rs17249754 and rs1401982 were associated with asymptomatic LAS in stroke-free Chinese hypertension patients and might benefit early recognition of LAS patients in clinical practice.
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Affiliation(s)
- Dewei An
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Jin Zhang
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Xiaofeng Tang
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Pingjin Gao
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Yan Li
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Yan Wang
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Dingliang Zhu
- a Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, State Key Laboratory of Medical Genomics, Shanghai Institute of Hypertension, Ruijin Hospital , Shanghai Jiao Tong University School of Medicine , Shanghai , China
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Yang W, Rong X, Braileanu M, Jiang B, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J. Is Carotid Revascularization Safe for Patients with Concomitant Carotid Stenosis and Intracranial Aneurysms? World Neurosurg 2016; 93:11-8. [DOI: 10.1016/j.wneu.2016.05.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/18/2016] [Accepted: 05/20/2016] [Indexed: 11/28/2022]
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Risk Factors Associated with Ipsilateral Ischemic Events Following Carotid Endarterectomy for Carotid Artery Stenosis. World Neurosurg 2016; 89:611-9. [DOI: 10.1016/j.wneu.2015.11.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/20/2022]
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Abstract
With modern intensive medical therapy, the risk of ipsilateral stroke in patients with asymptomatic carotid stenosis (ACS) is below the risk of either carotid stenting or endarterectomy. Routine intervention for ACS is therefore not justified; approximately 90% of patients with ACS would be better off with intensive medical therapy. The few who could benefit can be identified by transcranial Doppler embolus detection or features of vulnerable plaque that can be imaged by 3-dimensional ultrasound, MRI or positron emission tomography/computed tomography; some of these methods are still in development.
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Ye Z, Bailey KR, Austin E, Kullo IJ. Family history of atherosclerotic vascular disease is associated with the presence of abdominal aortic aneurysm. Vasc Med 2015; 21:41-6. [PMID: 26566659 DOI: 10.1177/1358863x15611758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We investigated whether family history (FHx) of atherosclerotic cardiovascular disease (ASCVD) was associated with presence of abdominal aortic aneurysm (AAA). The study cohort comprised of 696 patients with AAA (70±8 years, 84% men) and 2686 controls (68±10 years, 61% men) recruited from noninvasive vascular and stress electrocardiogram (ECG) laboratories at Mayo Clinic. AAA was defined as a transverse diameter of abdominal aorta ⩾ 3 cm or history of AAA repair. Controls were not known to have AAA. FHx was defined as having at least one first-degree relative with aortic aneurysm or with onset of ASCVD (coronary, cerebral or peripheral artery disease) before age 65 years. FHx of aortic aneurysm or ASCVD were each associated with presence of AAA after adjustment for age, sex, conventional risk factors and ASCVD: adjusted odds ratios (OR; 95% confidence interval): 2.17 (1.66-2.83, p < 0.01) and 1.31 (1.08-1.59, p < 0.01), respectively. FHx of ASCVD remained associated with AAA after additional adjustment for FHx of aortic aneurysm: adjusted OR: 1.27 (1.05-1.55, p = 0.01). FHx of ASCVD in multiple arterial locations was associated with higher odds of having AAA: the adjusted odds were 1.23 times higher for each additionally affected arterial location reported in the FHx (1.08-1.40, p = 0.01). Our results suggest both unique and shared environmental and genetic factors mediating susceptibility to AAA and ASCVD.
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Affiliation(s)
- Zi Ye
- Division of Cardiovascular Diseases and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Kent R Bailey
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Erin Austin
- Division of Cardiovascular Diseases and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Iftikhar J Kullo
- Division of Cardiovascular Diseases and the Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
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Markus HS, Bevan S. Mechanisms and treatment of ischaemic stroke--insights from genetic associations. Nat Rev Neurol 2014; 10:723-30. [PMID: 25348005 DOI: 10.1038/nrneurol.2014.196] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The precise pathophysiology of ischaemic stroke is unclear, and a greater understanding of the different mechanisms that underlie large-artery, cardioembolic and lacunar ischaemic stroke subtypes would enable the development of more-effective, subtype-specific therapies. Genome-wide association studies (GWASs) are identifying novel genetic variants that associate with the risk of stroke. These associations provide insight into the pathophysiological mechanisms, and present opportunities for novel therapeutic approaches. In this Review, we summarize the genetic variants that have been linked to ischaemic stroke in GWASs to date and discuss the implications of these associations for both our understanding and treatment of ischaemic stroke. The majority of genetic variants identified are associated with specific subtypes of ischaemic stroke, implying that these subtypes have distinct genetic architectures and pathophysiological mechanisms. The findings from the GWASs highlight the need to consider whether therapies should be subtype-specific. Further GWASs that include large cohorts are likely to provide further insights, and emerging technologies will complement and build on the GWAS findings.
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Affiliation(s)
- Hugh S Markus
- Stroke Research Group, Department of Neurology, R3, Box 83, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Steve Bevan
- Stroke Research Group, Department of Neurology, R3, Box 83, University of Cambridge, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
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