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Chausson N, Olindo S, Laborne FX, Aghasaryan M, Renou P, Soumah D, Debruxelles S, Altarcha T, Poli M, L'Hermitte Y, Sagnier S, Toudou-Daouda M, Aminou-Tassiou NR, Bentamra L, Benmoussa N, Alecu C, Imbernon C, Smadja L, Ouanounou G, Rouanet F, Sibon I, Smadja D. Second-dose intravenous thrombolysis with tenecteplase in alteplase-resistant medium-vessel-occlusion strokes: A retrospective and comparative study. Eur Stroke J 2024:23969873241254936. [PMID: 38829011 DOI: 10.1177/23969873241254936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase. PATIENTS AND METHODS This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup. RESULTS Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations. CONCLUSION In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05809921.
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Affiliation(s)
- Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
| | | | | | - Manvel Aghasaryan
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Pauline Renou
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Djibril Soumah
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Tony Altarcha
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Mathilde Poli
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Yann L'Hermitte
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | | | | | - Leila Bentamra
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Narimane Benmoussa
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Cosmin Alecu
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Carole Imbernon
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Léonard Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Gary Ouanounou
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Igor Sibon
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
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Ma Y, Xiang H, Busse JW, Yao M, Guo J, Ge L, Li B, Luo X, Mei F, Liu J, Wang Y, Liu Y, Li W, Zou K, Li L, Sun X. Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies. J Neurol 2024; 271:2309-2323. [PMID: 38436679 DOI: 10.1007/s00415-024-12243-1] [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: 01/07/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Alteplase is the current standard of care for acute ischemic stroke. Tenecteplase is a newer fibrinolytic agent with preferable administration and lower costs; however, its comparative effectiveness to alteplase remains uncertain. We set out to perform a systematic review and meta-analysis to establish the benefits and harms of tenecteplase versus alteplase for acute ischemic stroke. METHODS We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from inception to April 2023 for randomized and non-randomized studies that compared tenecteplase versus alteplase for acute ischemic stroke. Paired reviewers independently assessed risk of bias and extracted data. We performed both conventional meta-analyses and Bayesian network meta-analyses (NMA) with random-effects models and used the GRADE approach to evaluate the certainty of evidence. Our primary efficacy outcome was excellent functional outcome at 3 months, defined as a score of 0-1 on the modified Rankin Scale. Our primary safety outcomes were symptomatic intracranial hemorrhage and all-cause mortality. RESULTS Thirty-six studies were eligible for review, including 12 randomized (n = 5533) and 24 non-randomized studies (n = 44,956). Moderate certainty evidence showed that there was no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months (odds ratio [OR], 1.10; 95% CI 0.98-1.23; risk difference [RD] 2.4%, 95% CI - 0.5 to 5.2), while moderate certainty evidence from NMA suggested that 0.25 mg/kg tenecteplase significantly improved excellent functional outcome at 3 months (OR, 1.16; 95% credible interval 1.02-1.32). Moderate certainty evidence showed that, compared to alteplase, tenecteplase may make little to no difference in the prevalence of symptomatic intracranial hemorrhage (OR, 1.12; 95% CI 0.79-1.59; RD 0.3%, 95% CI - 0.5 to 1.4), and probably reduces all-cause mortality (adjusted odds ratio [aOR], 0.44; 95% CI 0.30-0.64; RD - 4.6%; 95% CI - 5.8 to - 2.9). CONCLUSIONS Moderate certainty evidence suggested that there was little to no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months and the risk of symptomatic intracranial hemorrhage, while compared to alteplase, tenecteplase probably reduce all-cause mortality. Administration of 0.25 mg/kg tenecteplase after acute ischemic stroke is suggestive of increasing the proportion of patients that achieve excellent functional outcome at 3 months.
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Affiliation(s)
- Yu Ma
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Hunong Xiang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jason W Busse
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Anaesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Minghong Yao
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, 730000, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Bo Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Xiaochao Luo
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Fan Mei
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jiali Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yuning Wang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yanmei Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Wentao Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Kang Zou
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Ling Li
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
| | - Xin Sun
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
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Carrillo Navarrete KA, Chapa González C. Hemiplegia in acute ischemic stroke: A comprehensive review of case studies and the role of intravenous thrombolysis and mechanical thrombectomy. IBRAIN 2024; 10:59-68. [PMID: 38682021 PMCID: PMC11045183 DOI: 10.1002/ibra.12146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 05/01/2024]
Abstract
Acute ischemic stroke is a significant health concern worldwide, often leading to long-term disability and decreased quality of life. Rapid and appropriate treatment is crucial for achieving optimal outcomes in these patients. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are two commonly used interventions for acute ischemic stroke, but their effectiveness in improving neurological symptoms and functional outcomes in patients with hemiplegia remains uncertain. The aim of this work was to evaluate the impact of IVT and MT within a 4.5-h time frame on patients with acute ischemic stroke and hemiplegia. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that assessed the impact of IVT and MT within 4.5-h on hemiplegia in patients with an acute ischemic stroke were included. Data were extracted and analyzed to determine the overall effects of these interventions. Most included case reports indicate positive outcomes in terms of neurological symptom improvement and functional recovery in patients with hemiplegia after receiving IVT and MT within the specified time frame. However, the heterogeneity among the patients and the limited use of IVT due to contraindications posed challenges in determining the most effective treatment option. The findings from the included studies demonstrate that both interventions led to a decrease in National Institutes of Health Stroke Scale scores, indicating an improvement in neurological symptoms. The results highlight the beneficial effects of early thrombolytic interventions and MT on the neurological status and functional outcomes of patients with an acute ischemic stroke.
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Affiliation(s)
- Karen Adriana Carrillo Navarrete
- Instituto de Ingeniería y TecnologíaUniversidad Autónoma de Ciudad JuárezCiudad Juárez, ChihuahuaMéxico
- Grupo de Nanomedicina, Laboratorio de Integración de Datos y Evidencia en Revisiones de Salud y Ciencia, LIDERSCUniversidad Autónoma de Ciudad JuárezCiudad Juárez, ChihuahuaMéxico
| | - Christian Chapa González
- Instituto de Ingeniería y TecnologíaUniversidad Autónoma de Ciudad JuárezCiudad Juárez, ChihuahuaMéxico
- Grupo de Nanomedicina, Laboratorio de Integración de Datos y Evidencia en Revisiones de Salud y Ciencia, LIDERSCUniversidad Autónoma de Ciudad JuárezCiudad Juárez, ChihuahuaMéxico
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Palaiodimou L, Katsanos AH, Turc G, Romoli M, Theodorou A, Lemmens R, Sacco S, Velonakis G, Vlachopoulos C, Tsivgoulis G. Tenecteplase for the treatment of acute ischemic stroke in the extended time window: a systematic review and meta-analysis. Ther Adv Neurol Disord 2024; 17:17562864231221324. [PMID: 38193030 PMCID: PMC10771742 DOI: 10.1177/17562864231221324] [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: 08/17/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024] Open
Abstract
Background Outcome data regarding the administration of tenecteplase (TNK) to acute ischemic stroke (AIS) patients presenting in the extended time window are limited. Objectives We aimed to assess the current evidence regarding the efficacy and safety of TNK at a dose of 0.25 mg/kg for AIS treatment in the extended time window. Design A systematic review and meta-analysis was conducted including all available randomized-controlled clinical trials (RCTs) that compared TNK 0.25 mg/kg versus no thrombolysis in AIS patients presenting in the extended time window (>4.5 h after last-seen-well or witnessed onset). Data sources and methods Eligible studies were identified by searching Medline, Scopus, and international conference abstracts. The predefined efficacy outcomes of interest were 3-month excellent functional outcome [defined as the modified Rankin Scale (mRS) score ⩽1; primary outcome], 3-month good functional outcome (mRS ⩽ 2), 3-month reduced disability (⩾1-point reduction across all mRS scores). We determined symptomatic intracranial hemorrhage (sICH), any ICH and 3-month mortality as safety endpoints. A random-effects model was used to calculate risk ratios (RRs) and common odds ratios (cORs) with corresponding 95% confidence intervals (CIs). Results Three RCTs were included comprising 556 patients treated with TNK versus 560 controls. TNK 0.25 mg/kg was associated with a higher likelihood of 3-month excellent functional outcome compared to controls (RR = 1.17; 95% CI = 1.01-1.36; I2 = 0%), whereas there was no difference regarding good functional outcome (RR = 1.05; 95% CI = 0.94-1.17; I2 = 0%) and reduced disability (adjusted cOR = 1.14; 95% CI = 0.92-1.40; I2 = 0%) at 3 months. The risks of sICH (RR = 1.67; 95% CI = 0.70-4.00; I2 = 0%), any ICH (RR = 1.08; 95% CI = 0.90-1.29; I2 = 0%) and 3-month mortality (RR = 1.10; 95% CI = 0.81-1.49; I2 = 0%) were similar between the groups. Conclusion Based on data from three RCTs showing increased efficacy and a favorable safety profile of TNK in the treatment of AIS in the extended time window, continuing efforts of ongoing RCTs in the field are clearly supported. Trial registration PROSPERO registration ID: CRD42023448707.
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Affiliation(s)
- Lina Palaiodimou
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis H. Katsanos
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1266, Paris, France
- FHU NeuroVasc, Paris, France
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Aikaterini Theodorou
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Division of Experimental Neurology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Georgios Velonakis
- Research Unit of Radiology, Second Department of Radiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12462, Greece Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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Shen Z, Bao N, Tang M, Yang Y, Li J, Liu W, Jiang G. Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurol Ther 2023; 12:1553-1572. [PMID: 37552459 PMCID: PMC10444744 DOI: 10.1007/s40120-023-00530-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION In recent years, as one of the drugs for the treatment of acute ischemic stroke (AIS), the clinical application of tenecteplase is still controversial. Therefore, we aimed to evaluate the safety and efficacy of tenecteplase versus alteplase to guide clinical practice. METHODS A search of PubMed, MEDLINE, EMBASE, Cochrane Library, and Web of Science databases until February 15, 2023 was conducted to identify eligible articles. The quality of the included studies was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 and Stata 17 were used to perform the meta-analysis and detect publication bias, and risk ratios (RRs) with 95% confidence intervals (95% CIs) were reported for each outcome measure. RESULTS A total of 1326 records were retrieved in this meta-analysis. As a result of the limited reports on tenecteplase in patients with AIS and the lack of high-quality randomized controlled trials (RCTs), and considering the impact of publication bias, we did not include any of these studies published before 2015. Ultimately we included 16 RCTs with a total of 7508 patients, including 3940 patients treated with alteplase and 3568 patients treated with tenecteplase. Tenecteplase was associated with better early neurological improvement (RR 0.10; 95% CI 0.00-0.19; P = 0.04), recanalization of blood vessels (RR 0.24; 95% CI 0.07-0.40; P = 0.01), and 90-day excellent neurological recovery (RR 0.12; 95% CI 0.01-0.24; P = 0.04). In addition, there were no significant differences in other efficacy and safety outcomes between the two groups. The funnel plot and Begg's as well as Egger's tests showed no significant publication bias. CONCLUSIONS This meta-analysis showed that tenecteplase was not inferior to alteplase in early thrombolytic therapy in patients with AIS, and was even better than alteplase on some efficacy outcomes with no significant differences in safety. However, as a result of some inherent limitations of this study, more high-quality prospective clinical studies are needed to confirm these results.
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Affiliation(s)
- Ziyi Shen
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Nana Bao
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ming Tang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yang Yang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jia Li
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Wei Liu
- Department of Neurology, Nanbu County Hospital Affiliated to North Sichuan Medical College, Nanchong, Sichuan, China.
| | - Guohui Jiang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China.
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China.
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