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  • 1
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    Validity of HAT Score for Predicting Symptomatic Intracranial Hemorrhage in Acute Stroke Patients with Proximal Occlusions: Data from Randomized Trials of Sonothrombolysis
    S. Karger AG ; 2011
    In:  Cerebrovascular Diseases Vol. 31, No. 5 ( 2011), p. 471-476
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 31, No. 5 ( 2011), p. 471-476
    Abstract: 〈 i 〉 Background: 〈 /i 〉 The Hemorrhage after Thrombolysis (HAT) score has recently been introduced as a practical scale for risk stratification of intracranial hemorrhage (ICH) in patients receiving intravenous tissue plasminogen activator (tPA). We aimed to externally validate and evaluate the predictive ability of the HAT score in patients with proximal arterial occlusions (PAO) enrolled into randomized clinical trials of sonothrombolysis. 〈 i 〉 Methods: 〈 /i 〉 The HAT score (range 0, minimum risk, to 5, maximum risk) was retrospectively calculated for each patient using clinical trial data (baseline NIHSS, extent of hypodensity on CT, history of diabetes mellitus and serum glucose). Symptomatic ICH (sICH) was defined as imaging evidence of ICH with clinical worsening (NIHSS ≧4) within 72 h from stroke onset. The predictive ability of the HAT score for sICH and any ICH (both asymptomatic and symptomatic) was calculated using c statistics. 〈 i 〉 Results: 〈 /i 〉 A total of 161 tPA-treated patients (mean age 68 ± 13 years, 58% men, median NIHSS 16, interquartile range 9) with PAO were randomized in TUCSON (n = 35) and CLOTBUST (n = 126). sICH occurred in 9 (5.6%) cases, and 6 had asymptomatic ICH. The rates of sICH for the corresponding HAT scores were: HAT 0–1: 3%; 2: 9%; 3: 14%; 4–5: 14%. The risk of sICH (c statistic 0.72, 95% CI: 0.58–0.86; p = 0.027) and any ICH (c statistic 0.70, 95% CI: 0.58–0.82; p = 0.011) increased with higher HAT scores. Higher HAT scores were also associated with higher likelihood of persisting occlusion (c statistic 0.63, 95% CI: 0.54–0.72; p = 0.004). 〈 i 〉 Conclusions: 〈 /i 〉 The HAT score has reasonable external validity for predicting the risk of sICH following intravenous thrombolysis in patients with PAO. Moreover, higher HAT scores appear to be associated with higher likelihood of persisting occlusion in tPA-treated patients.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000324387
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2011
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  • 2
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    Normal Magnetic Resonance Perfusion-Weighted Imaging in Lacunar Infarcts Predicts a Low Risk of Early Deterioration
    S. Karger AG ; 2009
    In:  Cerebrovascular Diseases Vol. 28, No. 2 ( 2009), p. 151-156
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 28, No. 2 ( 2009), p. 151-156
    Abstract: 〈 i 〉 Background: 〈 /i 〉 Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome. 〈 i 〉 Methods: 〈 /i 〉 Patients with lacunar stroke or TIA were selected from a prospective MR imaging study. MRI was performed within 24 h of the event and follow-up imaging completed at 30 or 90 days. Baseline perfusion maps were qualitatively assessed and infarct volumes measured. Early clinical deterioration (NIHSS worsening of ≥3 points within 72 h of event) and 90-day modified Rankin Scale score (mRS) were recorded. 〈 i 〉 Results: 〈 /i 〉 Twenty-two patients were included. Fifteen (68.2%) had abnormal PWI at the site of the diffusion-weighted imaging lesion. Patients with abnormal PWI were more likely to have stroke than TIA as their index event (RR 2.2, 95% CI 0.9–5.2, p = 0.02). Early clinical deterioration occurred in 4 patients (18.2%), all of whom had abnormal PWI. PWI lesions were not associated with a higher 90-day NIHSS or mRS score, nor did they predict infarct volume growth. 〈 i 〉 Conclusions: 〈 /i 〉 MR-PWI abnormalities are seen in two thirds of lacunar infarcts, and are associated with stroke rather than TIA. Normal PWI identifies patients at low risk of early clinical deterioration.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000225908
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2009
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  • 3
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    Does Current Oral Antiplatelet Agent or Subtherapeutic Anticoagulation Use Have an Effect on Tissue-Plasminogen-Activator-Mediated Recanalization Rate in Patients with Acute Ischemic Stroke?
    S. Karger AG ; 2010
    In:  Cerebrovascular Diseases Vol. 30, No. 5 ( 2010), p. 508-513
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 30, No. 5 ( 2010), p. 508-513
    Abstract: 〈 i 〉 Objective: 〈 /i 〉 Our goal is to assess if current antiplatelet (AP) use has an effect on recanalization rate and outcome in acute stroke patients. 〈 i 〉 Methods: 〈 /i 〉 We conducted a retrospective analysis of acute stroke patients who received intravenous (IV) recombinant tissue plasminogen activator (rt-PA) and had transcranial Doppler examination within 3 h of symptom onset. The TCD findings were interpreted using the Thrombolysis in Brain Ischemia flow grading system as persistent arterial occlusion, reocclusion or complete recanalization. Complete recanalization was defined as established Thrombolysis in Brain Ischemia 4 or 5 within 2 h of IV rt-PA. The patients were divided based on their current use of AP agents. Comparisons were made between the different groups based on recanalziation rate, reocclusion and good long-term outcome (mRS ≤2) using χ 〈 sup 〉 2 〈 /sup 〉 test. Multiple regression analysis was used to identify AP use as a predictor for recanalization and outcome including symptomatic intracranial hemorrhage after controlling for age, baseline NIHSS score, time to treatment, previous vascular event, hypertension and diabetes mellitus. 〈 i 〉 Results: 〈 /i 〉 Two hundred and eighty-four patients were included; 154 (54%) males, 130 (46%) females, with a mean age of 69.5 ± 13 years. The median baseline NIHSS score was 16 ± 5. The median time to TCD examination was 131 ± 38 min from symptom onset. The median time to IV rt-PA was 140 ± 34 min. One hundred eighty patients were not on AP prior to their stroke, 76 were on aspirin, 15 were on clopidogrel, 2 were on aspirin-dipyridamole combination, 2 were on both aspirin and clopidogrel, and 9 patients on subtherapeutic coumadin. In patients who were naïve to AP, 68/178 (38.2%) had complete recanalization, whereas in the AP group, 25/91 (28%) had complete recanalization. Patients on aspirin alone had a lower recanalization rate (16/72) as compared to those not on AP (22 vs. 39%) (p = 0.017), while those on clopidogrel had higher rates of complete recanalization (9/19, 60%). There was no difference in the rate of symptomatic intracranial hemorrhages in patients on AP agents as compared to those not on AP (9/180, 5% vs. 9/95, 9.5%) (p = 0.13). A good long-term outcome (mRS ≤2) was achieved in 85/160 (53%) of the patients naïve to AP and in 33/84 (39%) of the patients on AP (p = 0.035). In multiple regression, AP use was not a predictor of either recanalization rate (p = 0.057) or good outcome (p = 0.27). 〈 i 〉 Conclusions: 〈 /i 〉 No correlation was found between AP use and recanalization rate and good outcome in patients with acute stroke who received IV rt-PA treatment. Prior AP use should not defer patients from receiving IV rt-PA treatment in an acute stroke setting.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000319029
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2010
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  • 4
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    Malignant Profile Detected by CT Angiographic Information Predicts Poor Prognosis despite Thrombolysis within Three Hours from Symptom Onset
    S. Karger AG ; 2010
    In:  Cerebrovascular Diseases Vol. 29, No. 6 ( 2010), p. 584-591
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 29, No. 6 ( 2010), p. 584-591
    Abstract: 〈 i 〉 Objective: 〈 /i 〉 A malignant profile of early brain ischemia has been demonstrated in the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) trial. Patients with a malignant profile had a low chance for an independent functional outcome despite thrombolysis within 3–6 h. We sought to determine whether CT angiography (CTA) could identify a malignant imaging profile within 3 h from symptom onset. 〈 i 〉 Methods: 〈 /i 〉 We studied consecutive patients (04/02–09/07) with anterior circulation stroke who received CTA before intravenous thrombolysis within 3 h. We assessed the Alberta Stroke Program Early CT Score (ASPECTS) on CTA source images (CTASI). Intracranial thrombus burden on CTA was assessed with a novel 10-point clot burden score (CBS). We analyzed percentages independent (modified Rankin Scale score ≤2) and fatal outcome at 3 months and parenchymal hematoma rates across categorized combined CTASI-ASPECTS + CBS score groups where 20 is best and 0 is worst. 〈 i 〉 Results: 〈 /i 〉 We identified 114 patients (median age 73 years [interquartile range 61–80], onset-to-tPA time 129 min [95–152] ). Among 24 patients (21%) with extensive hypoattenuation on CTASI and extensive thrombus burden (combined score ≤10), only 4% (1/24) were functionally independent whereas mortality was 50% (12/24). In contrast, 57% (51/90) of patients with less affected scores (combined score 11–20) were functionally independent and mortality was 10% (9/90; p 〈 0.001). Parenchymal hematoma rates were 30% (7/23) vs. 8% (7/88), respectively (p = 0.008). 〈 i 〉 Conclusion: 〈 /i 〉 CTA identifies a large hyperacute stroke population with high mortality and low likelihood for independent functional outcome despite early thrombolysis.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000311079
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2010
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  • 5
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    Importance of Leukoaraiosis on CT for Tissue Plasminogen Activator Decision Making: Evaluation of the NINDS rt-PA Stroke Study
    S. Karger AG ; 2008
    In:  Cerebrovascular Diseases Vol. 26, No. 2 ( 2008), p. 120-125
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 26, No. 2 ( 2008), p. 120-125
    Abstract: 〈 i 〉 Background: 〈 /i 〉 Leukoaraiosis is associated with microhemorrhages on T 〈 sub 〉 2 〈 /sub 〉 *-weighted magnetic resonance imaging of the brain. Such hemorrhages have been postulated to be responsible for symptomatic intracerebral hemorrhage (ICH) after thrombolytic treatment. We examined the relationship between small-vessel ischemic disease and symptomatic ICH within the NINDS rt-PA Stroke Study. 〈 i 〉 Methods: 〈 /i 〉 Baseline CT scans from the NINDS rt-PA Stroke Study were re-evaluated retrospectively by blinded expert CT readers using the van Swieten Score (vSS) for leukoaraiosis. The scale examined the severity of white-matter changes on 3 serial CT slices and graded separately for the 2 distinct regionsanterior and posterior to the central sulcus: 0 = no lesion, 1 = partlyinvolving the white matter, and 2 = extending up to the cortex. 〈 i 〉 Results: 〈 /i 〉 603 CT scans were interpreted. The risk of symptomatic ICH increased with higher vSS in both the placebo and treatment groups. The absolute risk of symptomatic hemorrhage was 7.9% in the rt-PA-treated cohort among patients with severe white-matter disease (vSS = 3–4) versus 2.9% receiving placebo. Among severe leukoaraiosis patients (vSS = 3–4), no differential treatment effect was seen with rt-PA patients achieving better outcomes than placebo, modified Rankin score 0–1 in 31.6% of rt-PA-treated versus 14.7% of placebo-treated patients. 〈 i 〉 Conclusion: 〈 /i 〉 The results from the present study do not support the concept that leukoaraiosis present on baseline noncontrast CT scanning is critical to thrombolysis decision making in the first 3 h from symptom onset. No clear leukoaraiosis threshold was identified below which no benefit or harm could be seen from intravenous rt-PA therapy.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000139658
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2008
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  • 6
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    Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset
    S. Karger AG ; 2018
    In:  Cerebrovascular Diseases Vol. 45, No. 5-6 ( 2018), p. 263-269
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 45, No. 5-6 ( 2018), p. 263-269
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6–12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the ­hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0–1 at 3 months after stroke included as a dependent variable, were constructed. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0–1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0–1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28–61.60]). 〈 b 〉 〈 i 〉 Conclusions: 〈 /i 〉 〈 /b 〉 Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6–12 h after LSN. EVT at 6–12 h in a predominantly Asian cohort resulted in better outcomes.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000489894
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2018
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  • 7
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    Computed Tomographic Parameters Predicting Fatal Outcome in Large Middle Cerebral Artery Infarction
    S. Karger AG ; 2003
    In:  Cerebrovascular Diseases Vol. 16, No. 3 ( 2003), p. 230-235
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 16, No. 3 ( 2003), p. 230-235
    Abstract: 〈 i 〉 Background: 〈 /i 〉 Large middle cerebral artery (MCA) ischaemic stroke when associated with extensive mass effect can result in brain herniation and neurological death. As yet there are few guidelines to aid the selection of patients for aggressive interventional therapies, such as decompression hemicraniectomy and/or hypothermia. 〈 i 〉 Methods: 〈 /i 〉 We studied a cohort of patients from seven centres with large MCA infarction requiring neurocritical care. The purpose of this analysis was to assess the use of early radiological signs on follow-up computed tomographic (CT) signs performed within 48 h of stroke onset for predicting mortality at 30 days. The CT parameters assessed included horizontal displacement of the septum pellucidum, pineal shift, complete or partial infarction of the temporal lobe, involvement of additional vascular territories, and the presence of hydrocephalus. The primary outcome measure was in-hospital death within 30 days. 〈 i 〉 Results: 〈 /i 〉 One hundred and thirty-five patients who had follow-up CT scans within 48 h were identified from a total of 201 patients with large MCA infarction that received conventional medical therapy alone. The median age was 68 (range 29–99), 56% were female, and the median NIHSS category was 26–30 at 48 h. Among CT variables in univariable analysis, anteroseptal shift ≧5 mm, pineal shift ≧2 mm, complete temporal lobe infarction, involvement beyond the MCA territory, and moderate or severe hydrocephalus were equally predictive of death. Multivariable analysis adjusting for time to CT scan revealed the following predictors of fatal outcome: anteroseptal shift ≧5 mm (OR 10.9; 95% CI 3.2–37.6), NIHSS within 48 h 〉 20 (OR 6.6; 95% CI 2.3–19.3), and infarction beyond the MCA territory (OR 4.9; 95% CI 1.6–15.0). 〈 i 〉 Conclusions: 〈 /i 〉 We identified the role of early CT signs in predicting death following massive MCA infarction. The CT parameters anteroseptal shift ( 〉 5 versus ≤5 mm), pineal shift ≧2 mm, hydrocephalus, temporal lobe infarction, and other vascular territory infarction if present were predictive of fatal outcome. These CT parameters require prospective validation before they should be considered reliable markers for decision-making.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000071121
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2003
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  • 8
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    Residual Flow at the Site of Intracranial Occlusion on Transcranial Doppler Predicts Response to Intravenous Thrombolysis: A Multi-Center Study
    S. Karger AG ; 2009
    In:  Cerebrovascular Diseases Vol. 27, No. 1 ( 2009), p. 5-12
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 27, No. 1 ( 2009), p. 5-12
    Abstract: 〈 i 〉 Background: 〈 /i 〉 We examined if transcranial Doppler (TCD) flow findings at the site of intracranial occlusions predict outcomes of stroke patients receiving intravenous rt-PA treatment. 〈 i 〉 Subjects and Methods: 〈 /i 〉 TCD detected residual flow with the Thrombolysis in Brain Ischemia (TIBI) grading system before intravenous rt-PA bolus in patients with acute arterial intracranial occlusion. Timing and completion of early recanalization were measured for occlusive TIBI flow grades using TCD monitoring. Poor responders were defined as modified Rankin scores (mRS) 〉 2 at 3 months. 〈 i 〉 Results: 〈 /i 〉 A total of 361 patients with proximal arterial occlusion received intravenous rt-PA at 137.4 ± 36 min (median NIHSS 16). Mean age 69 ± 13, women: 168 (46.5%). Seventeen of 96 (17.7%) patients with TIBI 0, 41/124 (33.1%) with TIBI 1, 29/76 (38.2%) with TIBI 2 and 31/65 (47.7%) with TIBI 3 had achieved complete recanalization (p 〈 0.001). Higher NIHSS, SBP, glucose and lower TIBI grades were independent negative predictors of complete recanalization in the final logistic model. Patients with TIBI 0 had less probability of complete recanalization than patients with residual flow (TIBI 1–3) (OR 〈 sub 〉 adj 〈 /sub 〉 0.4, CI 95% 0.22–0.8, p = 0.008). Median time to recanalization in patients with TIBI 0 was longer (155 min, interquartile range 104–190 min) than with TIBI ≥1 (120 min, range 60–170 min, p = 0.01, Mann-Whitney U test). In the stepwise multiple linear regression models adjusting for baseline characteristics, the only 2 factors that independently associated with time to recanalization were: time to rt-PA treatment and the absent flow (TIBI 0) on baseline TCD. Absent flow (TIBI 0) was associated with a longer time of recanalization of 35.2 min (95% CI 0.3–70.1 min, p = 0.048). Poor outcomes at 3 months were found in 61.3% of patients with no residual flow (TIBI 0), 56.9% with minimal (TIBI 1), 51.5% with blunted (TIBI 2), and 33.9% with dampened (TIBI 3) flows (p = 0.012). Patients with TIBI 0 have a higher likelihood of poor outcome (OR 3.1, 95% CI 1.5–6.4, p = 0.002). Patients who achieved complete recanalization have OR 〈 sub 〉 adj 〈 /sub 〉 5.2 for good outcome (95% CI 2.8–9.8, p 〈 0.001). 〈 i 〉 Conclusions: 〈 /i 〉 The pretreatment residual flow at intracranial occlusion predicts the likelihood of complete recanalization, time of recanalization and long-term outcome. No detectable residual flow indicates the least chance to achieve recanalization and recovery with systemic thrombolysis and may support an early decision for combined endovascular rescue.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000172628
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2009
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  • 9
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    Etiologic Classification of TIA and Minor Stroke by A-S-C-O and Causative Classification System as Compared to TOAST Reduces the Proportion of Patients Categorized as Cause Undetermined
    S. Karger AG ; 2014
    In:  Cerebrovascular Diseases Vol. 38, No. 2 ( 2014), p. 121-126
    Details
    In: Cerebrovascular Diseases, S. Karger AG, Vol. 38, No. 2 ( 2014), p. 121-126
    Abstract: 〈 b 〉 〈 i 〉 Background: 〈 /i 〉 〈 /b 〉 The assortment of patients based on the underlying pathophysiology is central to preventing recurrent stroke after a transient ischemic attack and minor stroke (TIA-MS). The causative classification of stroke (CCS) and the A-S-C-O (A for atherosclerosis, S for small vessel disease, C for Cardiac source, O for other cause) classification schemes have recently been developed. These systems have not been specifically applied to the TIA-MS population. We hypothesized that both CCS and A-S-C-O would increase the proportion of patients with a definitive etiologic mechanism for TIA-MS as compared with TOAST. 〈 b 〉 〈 i 〉 Methods: 〈 /i 〉 〈 /b 〉 Patients were analyzed from the CATCH study. A single-stroke physician assigned all patients to an etiologic subtype using published algorithms for TOAST, CCS and ASCO. We compared the proportions in the various categories for each classification scheme and then the association with stroke progression or recurrence was assessed. 〈 b 〉 〈 i 〉 Results: 〈 /i 〉 〈 /b 〉 TOAST, CCS and A-S-C-O classification schemes were applied in 469 TIA-MS patients. When compared to TOAST both CCS (58.0 vs. 65.3%; p 〈 0.0001) and ASCO grade 1 or 2 (37.5 vs. 65.3%; p 〈 0.0001) assigned fewer patients as cause undetermined. CCS had increased assignment of cardioembolism (+3.8%, p = 0.0001) as compared with TOAST. ASCO grade 1 or 2 had increased assignment of cardioembolism (+8.5%, p 〈 0.0001), large artery atherosclerosis (+14.9%, p 〈 0.0001) and small artery occlusion (+4.3%, p 〈 0.0001) as compared with TOAST. Compared with CCS, using ASCO resulted in a 20.5% absolute reduction in patients assigned to the ‘cause undetermined' category (p 〈 0.0001). Patients who had multiple high-risk etiologies either by CCS or ASCO classification or an ASCO undetermined classification had a higher chance of having a recurrent event. 〈 b 〉 〈 i 〉 Conclusion: 〈 /i 〉 〈 /b 〉 Both CCS and ASCO schemes reduce the proportion of TIA and minor stroke patients classified as ‘cause undetermined.' ASCO resulted in the fewest patients classified as cause undetermined. Stroke recurrence after TIA-MS is highest in patients with multiple high-risk etiologies or cryptogenic stroke classified by ASCO.
    Type of Medium: Online Resource
    ISSN: 1015-9770 , 1421-9786
    URL: Article
    DOI: 10.1159/000365500
    Language: English
    Publisher: S. Karger AG
    Publication Date: 2014
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