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Telemedicine networks for acute stroke: an analysis of global coverage, gaps and opportunities. 治疗急性中风的远程医疗网络:对全球覆盖范围、差距和机遇的分析。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-26 DOI: 10.1177/17474930241298450
Christine Tunkl, Ayush Agarwal, Emily Ramage, Faddi Saleh Velez, Tamer Roushdy, Teresa Ullberg, Linxin Li, Leonardo Augusto Carbonera, Abdul Hanif Khan Yusof Khan, Bogdan Ciopleias, Zhe Kang Law, Aristeidis H Katsanos, Mirjam R Heldner, Maria Khan, Sarah Shali Matuja, Matias J Alet, Javier Lagos-Servellon, Jatinder S Minhas, Susanna Zuurbier, Maria Giulia Mosconi, Radhika Lotlikar, Ahmed Elkady, Stefan T Gerner, Shirsho Shreyan, Alexandra Krauss, Christoph Gumbinger, Padma Mv Srivastava, Pawel Kiper, Robin Ohannessian, Anne Berberich, Gisele Sampaio Silva, Anna Ranta

Background: Despite the proven efficacy of telestroke in improving clinical outcomes by providing access to specialized expertise and allowing rapid expert hyperacute stroke management and decision-making, detailed operational evidence is scarce, especially for less developed or lower - income regions.

Aim: We aimed to map the global telestroke landscape and characterize existing networks.

Methods: We employed a four-tiered approach to comprehensively identify telestroke networks, primarily involving engagement with national stroke experts, stroke societies, and international stroke authorities. A carefully designed questionnaire was then distributed to the leaders of all identified networks to assess these networks' structures, processes, and outcomes.

Results: We identified 254 telestroke networks distributed across 67 countries. High-income countries (HICs) concentrated 175 (69%) of the networks. No evidence of telestroke services was found in 58 (30%) countries. From the identified networks, 88 (34%) completed the survey, being 61 (71%) located in HICs. Network set-up was highly heterogenous, ranging from 17 (22%) networks with more than twenty affiliated hospitals, providing thousands of annual consultations using purpose-built highly specialized technology, to 11 (13%) networks with fewer than 120 consultations annually using generic videoconferencing equipment. Real-time video and image transfer was employed in 64 (75%) networks, while 62 (74%) conducting quality monitoring. Most networks established in the last three years were located in low- and middle-income countries (LMICs).

Conclusions: This comprehensive global survey of telestroke networks found significant variation in network coverage, set-up, and technology use. Most services are in HICs, and few services are in LMICs, although an emerging trend of new networks in these regions marks a pivotal moment in global telestroke care. The wide variation in quality monitoring practices across networks, with many failing to report key performance metrics, underscores the urgent need for standardized, resource-appropriate quality assurance measures that can be adapted to diverse settings.

背景:目的:我们旨在绘制全球远程卒中地图并描述现有网络的特征:方法:我们采用了四层方法来全面识别远程卒中网络,主要涉及国家卒中专家、卒中协会和国际卒中权威机构。然后,我们向所有已确定网络的领导者发放了一份精心设计的调查问卷,以评估这些网络的结构、流程和结果:结果:我们确定了分布在 67 个国家的 254 个远程卒中网络。高收入国家(HICs)集中了 175 个网络(69%)。58个国家(30%)没有发现远程卒中服务。在已确定的网络中,有 88 个(34%)完成了调查,其中 61 个(71%)位于高收入国家。网络设置的差异很大,有 17 个(22%)网络拥有 20 多家附属医院,使用专门设计的高度专业化技术,每年提供数千次会诊;也有 11 个(13%)网络使用普通视频会议设备,每年提供少于 120 次会诊。有 64 个(75%)网络采用了实时视频和图像传输技术,62 个(74%)网络进行了质量监控。过去三年中建立的大多数网络都位于中低收入国家(LMICs):这项关于远程卒中网络的全球综合调查发现,在网络覆盖、设置和技术使用方面存在很大差异。大多数服务在高收入国家,很少有服务在低收入国家,尽管这些地区新网络的出现标志着全球远程卒中医疗的关键时刻。不同网络的质量监测方法差异很大,许多网络没有报告关键的绩效指标,这突出表明迫切需要标准化的、适合资源的质量保证措施,以适应不同的环境。
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引用次数: 0
Early penumbral FLAIR changes predict tissue fate in patients with large vessel occlusions. 早期半影 FLAIR 变化可预测大血管闭塞患者的组织命运。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-21 DOI: 10.1177/17474930241289235
Lauranne Scheldeman, Pierre Seners, Anke Wouters, Patrick Dupont, Soren Christensen, Michael Mlynash, Caroline Arquizan, Adrien Ter Schiphorst, Vincent Costalat, Hilde Henon, Martin Bretzner, Jean-François Albucher, Christophe Cognard, Jean-Marc Olivot, Jeremy J Heit, Gregory W Albers, Maarten G Lansberg, Robin Lemmens

Background: In patients with an acute ischemic stroke, the penumbra is defined as ischemic tissue that remains salvageable when reperfusion occurs. However, the expected clinical recovery congruent with penumbral salvage is not always observed.

Aims: We aimed to determine whether the magnetic resonance imaging (MRI)-defined penumbra includes irreversible neuronal loss that impedes expected clinical recovery after reperfusion.

Methods: In the prospective French Acute Multimodal Imaging Study to Select Patients for Mechanical Thrombectomy (FRAME) and an observational cohort of patients with large vessel occlusions undergoing endovascular treatment, we quantified penumbral integrity by fluid-attenuated inversion recovery (FLAIR) changes. We studied the influence of recanalization status on the evolution of penumbral FLAIR changes and studied penumbral FLAIR changes as predictor of tissue fate and functional outcome on the 90-day modified Rankin Scale (mRS).

Results: Recanalization status did not modify the evolution of rFLAIR signal intensity (SI) over time in the total cohort, but was associated with lower SI in the FRAME subset (b = -0.06, p for interaction = 0.04). Median rFLAIR SI was higher at baseline in the subsequently infarcted penumbra compared to the salvaged (ratio = 1.07, standard deviation (SD) = 0.07 vs 1.03, SD = 0.06 p < 0.0001, n = 150). The severity and extent of rFLAIR SI changes did not predict 90-day functional outcome in univariate (p = 0.09) and multivariate logistic regression (p = 0.4).

Conclusions: Recanalization status did not influence the evolution of penumbral FLAIR changes. FLAIR SI changes in the baseline penumbra were associated with tissue fate, but not functional outcome.

背景:急性缺血性脑卒中患者的半影被定义为再灌注时仍可挽救的缺血组织。目的:我们旨在确定磁共振成像(MRI)定义的半影是否包括阻碍再灌注后预期临床恢复的不可逆神经元损失:在前瞻性的法国急性多模态成像研究(FRAME)和接受血管内治疗的大血管闭塞患者观察队列中,我们通过FLAIR变化量化了半影的完整性。我们研究了再通畅状态对半影FLAIR变化演变的影响,并研究了半影FLAIR变化作为组织命运和90天改良Rankin量表(mRS)功能结果的预测因子:再通畅状态并不改变rFLAIR信号强度(SI)随时间的变化,但在FRAME亚组中与较低的SI相关(b=-0.06,交互作用p=0.04)。随后梗死的半影中位rFLAIR SI基线高于挽救的半影(比值=1.07,标准差[SD] 0.07 vs 1.03,SD 0.06):再通畅状态并不影响半影 FLAIR 变化的演变。基线半影的FLAIR SI变化与组织命运有关,但与功能结果无关:支持本研究的数据可在合理要求下提供,但需签署数据访问协议。
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引用次数: 0
Stroke severity and outcomes in patients with intracerebral hemorrhage on anticoagulants and antiplatelet agents: An analysis from the Japan Stroke Data Bank. 使用抗凝剂和抗血小板药物的脑内出血患者的中风严重程度和预后:来自日本中风数据库的分析。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-21 DOI: 10.1177/17474930241292022
Yoshito Arakaki, Sohei Yoshimura, Kazunori Toyoda, Kazutaka Sonoda, Shinichi Wada, Michikazu Nakai, Jin Nakahara, Masayuki Shiozawa, Junpei Koge, Akiko Ishigami, Kaori Miwa, Takako Torii-Yoshimura, Junji Miyazaki, Yoshihiro Miyamoto, Kazuo Minematsu, Masatoshi Koga

Background and aim: Some patients with intracerebral hemorrhage are on antithrombotic agents at the time of the event and these may worsen outcome, but the relative risk of different oral anticoagulants and antiplatelet agents is uncertain. We determined associations between pre-onset intake of antithrombotic agents and initial stroke severity, and outcomes, in patients with intracerebral hemorrhage.

Methods: Patients with intracerebral hemorrhage admitted within 24 h after onset between January 2017 and December 2020 and recruited to the Japan Stroke Data Bank, a hospital-based multicenter prospective registry, were included. Enrolled patients were classified into four groups based on the type of antithrombotic agents being used on admission. The outcomes were the National Institutes of Health Stroke Scale (NIHSS) score on admission and modified Rankin Scale (mRS) of 5-6 at discharge.

Results: Of a total 9810 patients with intracerebral hemorrhage (4267 females; mean age = 70 ± 15 years), 77.1% were classified into the no-antithrombotic group, 13.2% into the antiplatelet group, 4.0% into the warfarin group, and 5.8% into the direct oral anticoagulant (DOAC) group. Median (interquartile range) NIHSS score on admission was 12 (5-22), 13 (5-26), 15 (5-30), and 13 (6-24), respectively, in the four groups. In multivariable analysis, the prestroke warfarin use was associated with higher NIHSS score (adjusted incidence rate ratio = 1.09 (95% confidence interval (CI) = 1.06-1.13), with the no-antithrombotic group as the reference), but the antiplatelet group (1.00 (95% CI = 0.98-1.02)) and DOAC group (0.98 (95% CI = 0.95-1.01)) were not. The rate of mRS 5-6 at discharge was 30.8%, 41.9%, 48.6%, and 41.5%, respectively, in the four groups. In multivariable analysis, prestroke warfarin use was associated with mRS 5-6 (adjusted odds ratio = 1.90 (95% CI = 1.28-2.81), with the no-antithrombotic group as the reference), but the antiplatelet group (1.12 (95% CI = 0.91-1.37)) and DOAC group (1.25 (95% CI = 0.88-1.77)) were not.

Conclusion: Patients who were taking warfarin prior to intracerebral hemorrhage onset suffered more severe intracerebral hemorrhage as evidenced by higher admission NIHSS and higher discharge mRS. In contrast, no increase in severity was seen with antiplatelet agents.

背景和目的:一些脑出血患者在发病时服用了抗血栓药物,这些药物可能会恶化预后,但不同口服抗凝剂和抗血小板药物的相对风险尚不确定。我们确定了脑出血患者发病前服用抗血栓药物与最初中风严重程度及预后之间的关系:方法:纳入 2017 年 1 月至 2020 年 12 月间发病后 24 小时内入院的脑出血患者,这些患者被纳入日本卒中数据库(一个基于医院的多中心前瞻性登记系统)。入选患者根据入院时使用的抗血栓药物类型分为四组。结果为入院时美国国立卫生研究院卒中量表(NIHSS)评分和出院时改良Rankin量表(mRS)5-6分:在9810名脑出血患者中(女性4267人,平均年龄(70±15)岁),77.1%的患者属于无抗血栓药物组,13.2%的患者属于抗血小板组,4.0%的患者属于华法林组,5.8%的患者属于直接口服抗凝剂(DOAC)组。四组患者入院时的 NIHSS 评分中位数(四分位数间距)分别为 12(5-22)、13(5-26)、15(5-30)和 13(6-24)。在多变量分析中,卒中前使用华法林与较高的 NIHSS 评分相关(调整后发病率比为 1.09 [95%置信区间 (CI),1.06-1.13],以无抗血栓组为参照),但抗血小板组(1.00 [95%CI,0.98-1.02])和 DOAC 组(0.98 [95%CI,0.95-1.01])则不相关。四组患者出院时 mRS 5-6 的比例分别为 30.8%、41.9%、48.6% 和 41.5%。在多变量分析中,卒中前服用华法林与 mRS 5-6 相关(调整后的比值比:1.90 [95%CI,1.28-2.81],以无抗血栓组为参照),但抗血小板组(1.12 [95%CI,0.91-1.37])和 DOAC 组(1.25 [95%CI,0.88-1.77])与之无关:结论:脑出血发病前服用华法林的患者脑出血更严重,表现为入院时NIHSS更高,出院时mRS更高。相比之下,服用抗血小板药物的患者病情严重程度没有增加。
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引用次数: 0
Investigating undiagnosed Fabry disease in young adults with ischemic stroke: A multicenter cohort study. 调查缺血性中风青年患者中未确诊的法布里病:多中心队列研究
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-18 DOI: 10.1177/17474930241289864
Po-Yu Lin, Tien-Yu Lin, Sheng-Feng Sung, Helen L Po, Li-Chi Hsu, Sung-Chun Tang, Yen-Chu Huang, Cheng-Yang Hsieh, Yung-Chu Hsu, Ren-Ying Wu, Cheng-Chi Hsieh, Pi-Shan Sung, Chih-Hung Chen

Background: The global prevalence of ischemic stroke in young adults is increasing, leading to a significant social impact. Fabry disease is a recognized cause of ischemic stroke in young patients, and although disease-modifying treatments are available, further evidence is needed to confirm their effectiveness in reducing the incidence of ischemic strokes.

Aims: This study aimed to identify undiagnosed Fabry disease in young adult patients with ischemic stroke in a Taiwanese cohort.

Methods: This multicenter, prospective cohort study enrolled patients aged 20-55 years who had experienced an ischemic stroke or transient ischemic attack (TIA) within 10 days, from 1 January 2016 to 31 December 2020. Screening for Fabry disease was performed using a dry blood test to measure α-galactosidase activity in male patients and blood globotriaosylsphingosine (lyso-Gb3) levels in female patients. For patients with positive screen results, genetic diagnosis of Fabry disease was pursued through Sanger sequencing of the GLA gene, covering all exons and a segment of intron 4.

Results: A total of 977 patients (659 male, 68%) were enrolled from seven hospitals across Taiwan. Four patients (0.4%, all male) had positive screening results, and two patients (0.2%) were genetically diagnosed with Fabry disease. Case 1 had the GLA c.658C>T mutation and experienced ischemic stroke in the bilateral occipital regions. Case 2 had the GLA c.640-801G>A mutation and experienced an ischemic stroke in the left superficial watershed area.

Conclusion: The prevalence of undiagnosed Fabry disease in this cohort of Taiwanese young adults with ischemic stroke or TIA was 0.3% among the young male population. Understanding the prevalence of undiagnosed Fabry disease in young adults with ischemic stroke could help shape future Fabry disease screening policies.

Data access statement: The collected data will be available upon reasonable request from the corresponding author.

背景:全球青壮年缺血性中风的发病率正在上升,对社会造成了重大影响。法布里病是年轻患者缺血性脑卒中的公认病因之一,虽然目前已有改变病情的治疗方法,但还需要进一步的证据来证实其在降低缺血性脑卒中发病率方面的有效性:这项多中心、前瞻性队列研究招募了 20 至 55 岁、2016 年 1 月 1 日至 2020 年 12 月 31 日 10 天内经历过缺血性脑卒中或短暂性脑缺血发作 (TIA) 的患者。法布里病筛查采用干血检测法,男性患者检测α-半乳糖苷酶活性,女性患者检测血液中球蛋白鞘氨醇(lyso-Gb3)水平。对筛查结果呈阳性的患者,通过对 GLA 基因进行 Sanger 测序(包括所有外显子和一段 4 号内含子),进行法布里病的基因诊断:结果:共有来自台湾 7 家医院的 977 名患者(659 名男性,占 68%)参与了研究。4名患者(0.4%,均为男性)的筛查结果呈阳性,2名患者(0.2%)被基因诊断为法布里病。病例 1 患有 GLA c.658C>T 突变,双侧枕部缺血性中风。病例 2 患有 GLA c.640-801G>A 突变,左侧浅分水岭区域发生缺血性中风:结论:在这批患有缺血性中风或 TIA 的台湾年轻男性人群中,未确诊法布里病的患病率为 0.3%。了解缺血性中风青壮年中未确诊法布里病的患病率有助于制定未来的法布里病筛查政策。
{"title":"Investigating undiagnosed Fabry disease in young adults with ischemic stroke: A multicenter cohort study.","authors":"Po-Yu Lin, Tien-Yu Lin, Sheng-Feng Sung, Helen L Po, Li-Chi Hsu, Sung-Chun Tang, Yen-Chu Huang, Cheng-Yang Hsieh, Yung-Chu Hsu, Ren-Ying Wu, Cheng-Chi Hsieh, Pi-Shan Sung, Chih-Hung Chen","doi":"10.1177/17474930241289864","DOIUrl":"10.1177/17474930241289864","url":null,"abstract":"<p><strong>Background: </strong>The global prevalence of ischemic stroke in young adults is increasing, leading to a significant social impact. Fabry disease is a recognized cause of ischemic stroke in young patients, and although disease-modifying treatments are available, further evidence is needed to confirm their effectiveness in reducing the incidence of ischemic strokes.</p><p><strong>Aims: </strong>This study aimed to identify undiagnosed Fabry disease in young adult patients with ischemic stroke in a Taiwanese cohort.</p><p><strong>Methods: </strong>This multicenter, prospective cohort study enrolled patients aged 20-55 years who had experienced an ischemic stroke or transient ischemic attack (TIA) within 10 days, from 1 January 2016 to 31 December 2020. Screening for Fabry disease was performed using a dry blood test to measure α-galactosidase activity in male patients and blood globotriaosylsphingosine (lyso-Gb3) levels in female patients. For patients with positive screen results, genetic diagnosis of Fabry disease was pursued through Sanger sequencing of the <i>GLA</i> gene, covering all exons and a segment of intron 4.</p><p><strong>Results: </strong>A total of 977 patients (659 male, 68%) were enrolled from seven hospitals across Taiwan. Four patients (0.4%, all male) had positive screening results, and two patients (0.2%) were genetically diagnosed with Fabry disease. Case 1 had the <i>GLA</i> c.658C>T mutation and experienced ischemic stroke in the bilateral occipital regions. Case 2 had the <i>GLA</i> c.640-801G>A mutation and experienced an ischemic stroke in the left superficial watershed area.</p><p><strong>Conclusion: </strong>The prevalence of undiagnosed Fabry disease in this cohort of Taiwanese young adults with ischemic stroke or TIA was 0.3% among the young male population. Understanding the prevalence of undiagnosed Fabry disease in young adults with ischemic stroke could help shape future Fabry disease screening policies.</p><p><strong>Data access statement: </strong>The collected data will be available upon reasonable request from the corresponding author.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142346719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Clinically relevant findings on 24-h head CT after acute stroke therapy: The 24-h CT score. 急性脑卒中治疗后 24 小时头部 CT 的临床相关结果:24 小时 CT 评分。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-16 DOI: 10.1177/17474930241289992
Bowei Zhang, Andrew J King, Barbara Voetsch, Scott Silverman, Lee H Schwamm, Xunming Ji, Aneesh B Singhal

Background: Routine head computed tomography (CT) is performed 24 h post-acute stroke thrombolysis and thrombectomy, even in patients with stable or improving clinical deficits. Predicting CT results that impact management could help prioritize patients at risk and potentially reduce unnecessary imaging.

Methods: In this institutional review board (IRB)-approved retrospective study, data from 1461 consecutive acute ischemic stroke patients at our Comprehensive Stroke Center (n = 8943, 2012-2022) who received intravenous thrombolysis or endovascular therapy, exhibited stable or improving 24-h exams, and underwent 24-h follow-up head CT per standard acute stroke care guidelines. CT reports 24 h post-stroke were reviewed for edema, mass effect, herniation, and hemorrhage. The primary outcome was any clinically relevant 24-h CT finding that led to changes in antithrombotic treatment or blood pressure goals, extended intensive care unit (ICU) stays or hospitalizations, neurosurgical interventions, or administration of mannitol or hypertonic saline. Multivariable logistic regression identified independent predictors of clinically meaningful CT abnormalities. A 24-h CT score was developed and cross-validated.

Results: The mean age was 70 years, with 47% women. The median National Institutes of Health Stroke Scale (NIHSS) score at admission was 12 (interquartile range (IQR): 6-18). Stroke-related abnormalities on 24-h CT were present in 325 patients (22.2%), with 183 (12.5%) showing clinically relevant findings. Age, admission NIHSS, and blood glucose levels were independent predictors of clinically relevant 24-h CT findings. The final model C statistic was 0.72 (95% confidence interval (CI): 0.68-0.76) in the derivation cohort and 0.72 (95% CI: 0.67-0.75) in bootstrapping validation. The 24-h CT score was developed using these predictors: NIHSS score 5-15 (+3); NIHSS score ⩾16 (+5); age < 75 years (+1); admission glucose ⩾ 140 mg/dL (+1). The prevalence of clinically relevant CT findings was 4.3% in the low-risk group (24-h CT score ⩽ 4), 11.3% in the medium-risk group (score 5), and 21.4% in the high-risk group (score ⩾ 6). The 24-h CT score demonstrated good calibration.

Conclusion: In patients undergoing thrombolysis or thrombectomy who undergo routine 24-h head CT despite remaining clinically stable or improving, only one in eight prove to have 24-h head CT findings that impact management. The 24-h CT score provides risk stratification that may improve resource utilization.

Data access statement: A.S. and B.Z. have full access to the data used in the analysis in this article. Deidentified data will be shared after ethics approval if requested by other investigators for purposes of replicating the results.

背景:急性卒中溶栓和血栓切除术后 24 小时常规进行头部计算机断层扫描(CT),即使是临床功能障碍稳定或改善的患者。预测影响治疗的 CT 结果有助于确定高危患者的优先次序,并有可能减少不必要的影像学检查:在这项经 IRB 批准的回顾性研究中,我们的综合卒中中心连续收治了 1461 名急性缺血性卒中患者(n=8943,2012-2022 年),这些患者接受了静脉溶栓或血管内治疗,24 小时检查结果显示病情稳定或好转,并根据标准急性卒中治疗指南接受了 24 小时随访头部 CT。对中风后 24 小时的 CT 报告进行审查,以确定是否存在水肿、肿块效应、疝和出血。主要结果是任何导致抗血栓治疗或血压目标改变、重症监护室住院时间延长或住院、神经外科干预或使用甘露醇或高渗盐水的临床相关 24 小时 CT 发现。多变量逻辑回归确定了具有临床意义的 CT 异常的独立预测因素。制定了 24 小时 CT 评分标准并进行了交叉验证:平均年龄为 70 岁,女性占 47%。入院时NIH卒中量表(NIHSS)评分中位数为12(IQR为6-18)。325名患者(22.2%)的24小时CT出现了与卒中相关的异常,其中183名患者(12.5%)出现了临床相关的结果。年龄、入院 NIHSS 和血糖水平是 24 小时 CT 临床相关结果的独立预测因素。推导队列的最终模型 C 统计量为 0.72(95% CI,0.68-0.76),自引导验证的最终模型 C 统计量为 0.72(95% CI,0.67-0.75)。24 小时 CT 评分就是利用这些预测因子得出的:NIHSS评分5-15分(+3);NIHSS评分≥16分(+5);年龄 结论:在接受溶栓或血栓切除术的患者中,尽管临床症状保持稳定或有所改善,但接受常规 24 小时头部 CT 检查的患者中,只有八分之一的患者的 24 小时头部 CT 检查结果会对治疗产生影响。24 小时 CT 评分可提供风险分层,从而提高资源利用率。
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引用次数: 0
Association of aspirin use with risk of intracerebral hemorrhage in patients without history of stroke or transient ischemic attack in the UK Biobank. 英国生物库中无中风或短暂性脑缺血发作史患者服用阿司匹林与脑内出血风险的关系
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-10 DOI: 10.1177/17474930241288367
Zijie Wang, Xueyun Liu, Shanyu Zhang, Xiao Hu, Yanghua Tian, Qi Li

Background: The association between aspirin use and the risk of intracerebral hemorrhage (ICH) among individuals without previous stroke events is inconclusive.

Aim: We investigated the association between regular aspirin use and ICH risk in middle-aged and older adults without previous stroke or transient ischemic attack (TIA).

Methods: This prospective population-based study included participants older than 40 years with no history of stroke or TIA from the UK Biobank. The main exposure was regular aspirin use. Cox regression analyses and propensity score matching analyses estimated the hazard ratios (HRs) for aspirin use for incident fatal and non-fatal ICH. We conducted pre-specified subgroup analyses for selecting individuals at high risk of ICH when using aspirin. Multiple sensitivity analyses were performed to test the robustness of our results.

Results: A total of 449,325 participants were included into final analyses (median (IQR) age 58 (50-63) years, 54.6% females), of whom 58,045 reported aspirin use. During a median follow-up of 12.75 (IQR: 12.03-13.47) years, 1557 (0.3%) incident ICH cases were identified, of which 399 (25.6%) were fatal. Aspirin was not associated with increased risk of overall (hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.95-1.27, P = 0.188), fatal (HR: 1.03, 95% CI: 0.78-1.36, P = 0.846) and non-fatal (HR: 1.12, 95% CI: 0.95-1.33, P = 0.186) ICH. Propensity score matching analysis showed similar results. Subgroup analysis indicated that aspirin use in individuals older than 65 years or with concurrent anticoagulant use was correlated with increased risk of ICH.

Conclusion: In this large cohort study of middle-aged and older adults without stroke or TIA events, there was no significant association between aspirin use and ICH risk in the real-world setting. However, it is possible that aspirin use in those aged over 65 years and concurrent anticoagulant treatment may increase the risk of ICH.

背景:目的:我们调查了无中风或短暂性脑缺血发作(TIA)史的中老年人定期服用阿司匹林与 ICH 风险之间的关系:这项基于人群的前瞻性研究纳入了英国生物库中 40 岁以上、无中风或 TIA 病史的参与者。主要暴露因素是定期服用阿司匹林。Cox 回归分析和倾向评分匹配分析估算了服用阿司匹林与发生致命性和非致命性 ICH 的危险比 (HRs)。我们进行了预设亚组分析,以筛选出使用阿司匹林时发生 ICH 的高风险人群。我们还进行了多重敏感性分析,以检验结果的稳健性:共有 449,325 名参与者被纳入最终分析(中位数 [IQR] 年龄 58 [50 - 63] 岁,54.6% 为女性),其中 58,045 人报告使用了阿司匹林。在中位数为 12.75(IQR 12.03 - 13.47)年的随访期间,共发现 1,557 例(0.3%)ICH 病例,其中 399 例(25-6%)为致命病例。阿司匹林与总体(HR 1.11,95% CI 0.95 - 1.27,P = 0.188)、致命(HR 1.03,95% CI 0.78 - 1.36,P = 0.846)和非致命(HR 1.12,95% CI 0.95 - 1.33,P = 0.186)ICH 风险增加无关。倾向评分匹配分析显示了相似的结果。亚组分析表明,65 岁以上人群服用阿司匹林或同时服用抗凝剂与 ICH 风险增加相关:结论:在这项针对无中风或 TIA 事件的中老年人的大型队列研究中,阿司匹林的使用与现实世界中的 ICH 风险无明显关联。然而,65 岁以上人群服用阿司匹林并同时接受抗凝治疗可能会增加 ICH 风险。
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引用次数: 0
Female hormonal and reproductive factors and the risk of subarachnoid hemorrhage. 女性荷尔蒙和生殖因素与蛛网膜下腔出血的风险。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-07 DOI: 10.1177/17474930241283377
Fang Cao, Junyu Liu, Yuge Wang, Qingyue He, Yuxin Guo, Junxia Yan

Background: Subarachnoid hemorrhage (SAH), primarily caused by rupture of intracranial aneurysm, has a high incidence rate in women. We aimed to evaluate the association between female hormonal and reproductive factors and SAH.

Methods: A prospective cohort of 226,469 participants from the UK Biobank was followed for a median period of 14.75 years. Cox proportional hazards models and restricted cubic splines were used to explore the associations between 13 major factors and SAH, including menarche age, menopausal status, age at menopause, reproductive lifespan, pregnancy history, age at first and last live births, number of live births, adverse fertility outcomes, history of oral contraception or hormone-replacement therapy (HRT) use, and surgical history of hysterectomy or bilateral oophorectomy.

Results: SAH occurred in 769 of participants during the follow-up period. Both women with a younger age at menarche (< 12 years) and post-menopausal women had a higher SAH risk (hazard ratio (HR), 1.28; 95% confidence interval (CI), 1.06-1.54) and (HR, 1.48; 95% CI, 1.10-1.99), respectively. A higher risk of SAH was identified in those with an earlier age at menopause (< 40 years: HR, 2.09; 95% CI, 1.43-3.06; 40-44 years: HR, 1.68; 95% CI, 1.23-2.29). A shorter reproductive lifespan (< 30 years) was associated with increased SAH risk (HR, 1.64; 95% CI, 1.28-2.11), while a longer reproductive lifespan (> 42 years) showed a protective effect (HR, 0.65; 95% CI, 0.55-0.77). Younger age at first live birth (< 24 years) was associated with SAH (HR, 1.39; 95% CI, 1.13-1.72). Hysterectomy (HR, 2.55; 95% CI, 2.12-3.05) or bilateral oophorectomy (HR, 1.51; 95% CI, 1.14-2.01) also predisposed women to SAH. Age at last live birth, number of live births, pregnancy history, adverse fertility outcomes, and HRT or oral contraceptive use were not associated with SAH.

Conclusions: Female hormonal and reproductive factors are important for evaluating SAH risk in women. In particular, earlier menopause is associated with an increased risk of SAH.

Data access statement: The data utilized in this study were sourced from a third party and are not publicly accessible. The UK Biobank data that support the findings of this research are available from the UK Biobank (www.ukbiobank.ac.uk), subject to review and approval by the UK Biobank.

背景蛛网膜下腔出血(SAH)主要由颅内动脉瘤破裂引起,女性发病率较高。我们旨在评估女性荷尔蒙和生殖因素与蛛网膜下腔出血之间的关系。方法 对英国生物库中的 226,469 名前瞻性队列参与者进行了中位 14.75 年的随访。采用Cox比例危险模型和限制性三次样条来探讨13个主要因素与SAH之间的关系,包括初潮年龄、绝经状态、绝经年龄、生育年限、妊娠史、首次和最后一次活产的年龄、活产次数、不良生育结局、口服避孕药或激素替代疗法(HRT)使用史以及子宫切除术或双侧输卵管切除术的手术史。初潮年龄较小(42 岁)的女性具有保护作用(HR,0.65;95%CI,0.55-0.77)。首次活产年龄较小(42 岁)的女性具有保护作用(HR 值为 0.65;95%CI 为 0.55-0.77
{"title":"Female hormonal and reproductive factors and the risk of subarachnoid hemorrhage.","authors":"Fang Cao, Junyu Liu, Yuge Wang, Qingyue He, Yuxin Guo, Junxia Yan","doi":"10.1177/17474930241283377","DOIUrl":"10.1177/17474930241283377","url":null,"abstract":"<p><strong>Background: </strong>Subarachnoid hemorrhage (SAH), primarily caused by rupture of intracranial aneurysm, has a high incidence rate in women. We aimed to evaluate the association between female hormonal and reproductive factors and SAH.</p><p><strong>Methods: </strong>A prospective cohort of 226,469 participants from the UK Biobank was followed for a median period of 14.75 years. Cox proportional hazards models and restricted cubic splines were used to explore the associations between 13 major factors and SAH, including menarche age, menopausal status, age at menopause, reproductive lifespan, pregnancy history, age at first and last live births, number of live births, adverse fertility outcomes, history of oral contraception or hormone-replacement therapy (HRT) use, and surgical history of hysterectomy or bilateral oophorectomy.</p><p><strong>Results: </strong>SAH occurred in 769 of participants during the follow-up period. Both women with a younger age at menarche (< 12 years) and post-menopausal women had a higher SAH risk (hazard ratio (HR), 1.28; 95% confidence interval (CI), 1.06-1.54) and (HR, 1.48; 95% CI, 1.10-1.99), respectively. A higher risk of SAH was identified in those with an earlier age at menopause (< 40 years: HR, 2.09; 95% CI, 1.43-3.06; 40-44 years: HR, 1.68; 95% CI, 1.23-2.29). A shorter reproductive lifespan (< 30 years) was associated with increased SAH risk (HR, 1.64; 95% CI, 1.28-2.11), while a longer reproductive lifespan (> 42 years) showed a protective effect (HR, 0.65; 95% CI, 0.55-0.77). Younger age at first live birth (< 24 years) was associated with SAH (HR, 1.39; 95% CI, 1.13-1.72). Hysterectomy (HR, 2.55; 95% CI, 2.12-3.05) or bilateral oophorectomy (HR, 1.51; 95% CI, 1.14-2.01) also predisposed women to SAH. Age at last live birth, number of live births, pregnancy history, adverse fertility outcomes, and HRT or oral contraceptive use were not associated with SAH.</p><p><strong>Conclusions: </strong>Female hormonal and reproductive factors are important for evaluating SAH risk in women. In particular, earlier menopause is associated with an increased risk of SAH.</p><p><strong>Data access statement: </strong>The data utilized in this study were sourced from a third party and are not publicly accessible. The UK Biobank data that support the findings of this research are available from the UK Biobank (www.ukbiobank.ac.uk), subject to review and approval by the UK Biobank.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142107457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Beyond Conventional Imaging: A Systematic Review and Meta-Analysis Assessing the Impact of Computed Tomography Perfusion on Ischemic Stroke Outcomes in the Late-Window. 超越传统成像:评估计算机断层扫描灌注对缺血性脑卒中晚期预后影响的系统性综述和荟萃分析》(A Systematic Review and Meta-Analysis Assessing the Impact of Computed Tomography Perfusion on Ishemic Stroke Outcomes in the Late-Window.
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-07 DOI: 10.1177/17474930241292915
Salah Elsherif, Brittney Legere, Ahmed Mohamed, Razan Saqqur, Nida Fatima, Maher Saqqur, Ashfaq Shuaib

Background: Non-contrast CT (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion imaging (CTP) is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window.

Methods: We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data was split into two groups: the CTP and control (NCCT+CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICH), mortality, and successful recanalization.

Results: There were 14 studies with 5,809 total patients in the final analysis: 2,602 received CTP and 3,202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (OR: 0.72, 95% CI 0.60-0.87, p<0.01) and significantly higher successful recanalization (OR: 1.42, 95% CI 1.06-1.94, p<0.01) compared to CTA-only patients. Analysis of other outcomes including functional independence (mRS 0-2), critical times, and intracranial hemorrhages were non-significant (p > 0.05).

Conclusion: The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.

背景:非对比 CT(NCCT)和 CT 血管造影(CTA)已成为急性卒中血管内治疗(EVT)的必要手段。如果在选择患者时增加 CT 灌注成像(CTP),可能会改善患者选择。我们的目的是分析在急性缺血性卒中(AIS)患者治疗中实施 CTP 的效果,以评估在晚期窗口期卒中预后是否存在差异:我们在 PubMed、Embase 和 Web of Sciences 数据库中检索了与 EVT 中的 CTA 和 CTP 相关的文章。收集到的患者数据分为两组:CTP组和对照组(NCCT+CTA)。评估的主要结果是改良Rankin量表(mRS)评分、症状性颅内出血(sICH)、死亡率和成功再通:共有14项研究的5809名患者参与了最终分析:2602名患者接受了CTP治疗,3202名患者属于对照组。CTP/CTA患者的90天卒中相关死亡率明显降低(OR:0.72,95% CI 0.60-0.87,P 0.05):该研究强调了 CTP 引导治疗作为晚期窗口期 EVT 选择的辅助工具的实用性。虽然增加 CTP 可降低死亡率,但良好的预后并未改善。要更清楚地了解将 CTP 纳入卒中成像的潜在优势或局限性,还需要进一步的证据。
{"title":"Beyond Conventional Imaging: A Systematic Review and Meta-Analysis Assessing the Impact of Computed Tomography Perfusion on Ischemic Stroke Outcomes in the Late-Window.","authors":"Salah Elsherif, Brittney Legere, Ahmed Mohamed, Razan Saqqur, Nida Fatima, Maher Saqqur, Ashfaq Shuaib","doi":"10.1177/17474930241292915","DOIUrl":"https://doi.org/10.1177/17474930241292915","url":null,"abstract":"<p><strong>Background: </strong>Non-contrast CT (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion imaging (CTP) is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window.</p><p><strong>Methods: </strong>We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data was split into two groups: the CTP and control (NCCT+CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICH), mortality, and successful recanalization.</p><p><strong>Results: </strong>There were 14 studies with 5,809 total patients in the final analysis: 2,602 received CTP and 3,202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (OR: 0.72, 95% CI 0.60-0.87, p<0.01) and significantly higher successful recanalization (OR: 1.42, 95% CI 1.06-1.94, p<0.01) compared to CTA-only patients. Analysis of other outcomes including functional independence (mRS 0-2), critical times, and intracranial hemorrhages were non-significant (p > 0.05).</p><p><strong>Conclusion: </strong>The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.</p>","PeriodicalId":14442,"journal":{"name":"International Journal of Stroke","volume":null,"pages":null},"PeriodicalIF":6.3,"publicationDate":"2024-10-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142390461","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment. 中风后的情绪化;诊断、病理生理学和治疗。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-04-11 DOI: 10.1177/17474930241242952
Niall M Broomfield, Joshua Blake, Fergus Gracey, Tom Steverson

Background: Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect.

Aim and methods: This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment.

Results: Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions.

Conclusions: More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.

每 5 名中风患者中就有 1 人在中风 6 个月后会出现中风后情绪低落,尽管这种情况很常见,但人们对这种中风症状的了解却很少。相关文献十分有限,尤其是与其他常见的神经系统疾病(如失语症和视力障碍)相比。本叙述性综述对这些文献进行了总结,为临床实践和未来研究提供参考。我们将讨论定义、发病率、神经生物学、诱发和促发因素以及治疗方法。越来越多的证据表明,与情绪表达或调节过程功能相关的特定区域受损、结构性通路中断以及相关血清素分泌和调节紊乱单独或共同导致了情绪化类型的表现。研究中使用了一系列情绪化测量工具,因此很难对不同研究进行比较。最近开发的 "近期卒中后情绪测试-问卷"(TEARS-Q)可以进行标准化评估。可供选择的治疗方案有限,而且很少有充分有效的治疗试验。抗抑郁药可能会减轻严重程度,但还需要更多的试验数据。目前还没有非药物干预的随机对照试验。我们需要开展更多的研究,以提高对这一常见致残症状的认识和治疗。最后,我们提出了该领域的研究重点和建议。
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引用次数: 0
PCSK9 Inhibitor with Statin Therapy for Intracranial Artery Stenosis ( PISTIAS): Rationale and design of a multicenter randomized controlled trial. PCSK9抑制剂与他汀类药物治疗颅内动脉狭窄(PISTIAS):多中心随机对照试验的原理与设计。
IF 6.3 2区 医学 Q1 CLINICAL NEUROLOGY Pub Date : 2024-10-01 Epub Date: 2024-08-15 DOI: 10.1177/17474930241270447
Xinzhi Hu, Zongmuyu Zhang, Caiyan Liu, Mingli Li, Yiyang Liu, Anqi Cheng, Qiuyu Yu, Haoyao Guo, Yinxi Zou, Li Zhou, Hebo Wang, Bo Song, Yong You, Jian Xia, Jingfen Zhang, Zhibing Ai, Qinjian Sun, Ju Han, Jing Liu, Baoquan Lu, Qiwen Deng, Guanzeng Li, Peng-Fei Wang, Xiangqing Li, Yi An, Bo Wu, Zhongrui Yan, Yining Wang, Wei-Hai Xu

Rationale: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors enable an additional 54-75% reduction in low-density lipoprotein cholesterol (LDL-C) in statin-treated patients, demonstrating plaque regression in coronary artery disease. However, the impact of achieving an extremely low level of LDL-C with PCSK9 inhibitors (e.g. Evolocumab) on symptomatic intracranial atherosclerosis remains unexplored.

Aim and hypothesis: To determine whether combining Evolocumab and statins achieves a more significant symptomatic intracranial plaque regression than statin therapy alone.

Sample size estimates: With a sample size of 1000 subjects, a two-sided α of 0.05, and 20% lost to follow-up, the study will have 83.3% power to detect the difference in intracranial plaque burden.

Methods and design: This is an investigator-initiated multicenter, randomized, open-label, outcome assessor-blinded trial, evaluating the impact of combining Evolocumab and statins on intracranial plaque burden assessed by high-resolution magnetic resonance imaging at baseline in patients undergoing a clinically indicated acute stroke or transient ischemic attack due to intracranial artery stenosis, and after 24 weeks of treatment. Subjects (n = 1000) were randomized 1:1 into two groups to receive either Evolocumab 140 mg every 2 weeks with statin therapy or statin therapy alone.

Study outcomes: The primary endpoint is the change in intracranial plaque burden assessed by high-resolution magnetic resonance imaging, performed at baseline and at the end of the 24-week treatment period.

Discussion: This trial will explore whether more significant intracranial plaque regression is achievable with the treatment of combining Evolocumab and statins, providing information about efficacy and safety data.

Trial registration number: ChiCTR2300068868; https://www.chictr.org.cn/.

理论依据:Protein convertase subtilisin/kexin type 9 (PCSK9) 抑制剂可使他汀类药物治疗患者的低密度脂蛋白胆固醇(LDL-C)额外降低 54% 至 75%,显示出冠状动脉疾病斑块的消退。然而,使用 PCSK9 抑制剂(如 evolocumabEvolocumab)达到极低水平的 LDL-C 对无症状颅内动脉粥样硬化的影响仍有待探索:目的和假设:确定将 evolocumabEvolocumab 和他汀类药物结合使用是否比单纯他汀类药物治疗能更显著地减少症状性颅内斑块:样本量估计:样本量为1000名受试者,双侧为0.05,20%的受试者失去随访,该研究将有83.3%的力量检测到颅内斑块负担的差异:这是一项由研究者发起的多中心、随机、开放标签、结果评估者盲法试验,旨在评估 EvolocumabEvolocumab 对因颅内动脉狭窄导致的临床急性中风或短暂性脑缺血发作患者基线时和治疗 24 周后通过高分辨率磁共振成像评估的颅内斑块负荷的影响。受试者(n = 1000)将按 1:1 随机分为两组,接受 evolocumabEvolocumab 140 毫克,每两周一次,同时接受他汀类药物治疗或仅接受他汀类药物治疗:主要终点是在基线和24周治疗期结束时通过高分辨率磁共振成像评估斑块负担的变化:该试验将探索他汀类药物和 PCSK9 抑制剂联合治疗是否能实现更显著的斑块消退,提供重要的疗效、机制和安全性数据信息:ChiCTR2300068868;https://www.chictr.org.cn/。
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引用次数: 0
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International Journal of Stroke
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