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Asiatic Acid Attenuates Infarct Volume, Mitochondrial

Dysfunction, and Matrix Metalloproteinase-9 Induction


After Focal Cerebral Ischemia
Ki Yong Lee, PhD; Ok-Nam Bae, PhD; Kelsey Serfozo; Siamk Hejabian; Ahmad Moussa;
Mathew Reeves, PhD; Wilson Rumbeiha, PhD; Scott D. Fitzgerald, DVM, PhD; Gary Stein, PharmD;
Seung-Hoon Baek, PhD; John Goudreau, DO, PhD; Mounzer Kassab, MD; Arshad Majid, MD

Background and Purpose—Asiatic acid (AA) has been shown to attenuate cerebral infarction in a mouse model of focal
ischemia and shows promise as a neuroprotective stroke therapy. To facilitate translation of these findings to clinical
studies, we determined pharmacokinetics, a dose–response relationship, the therapeutic time window, and efficacy using
multiple stroke models. We also explored potential mechanisms of action.
Methods—Escalating doses of intravenous AA were administered and serum concentrations were measured at multiple
time points for the pharmacokinetic studies. Subsequently, a dose–response relationship was determined followed by
administration at different intervals after the onset of ischemia to establish a therapeutic time window for
neuroprotection. Outcome measurements included both histological and behavioral. Mitochondrial function and matrix
metalloproteinase activity in controls and treated rats were also determined.
Results—The pharmacokinetic studies showed that AA (75 mg/kg) has a half-life of 2.0 hours. AA significantly decreased
infarct volume and improved neurological outcome even when administration was at time points up to 12 hours after
the onset of ischemia. Infarct volume was also significantly decreased in female rats and spontaneously hypertensive
rats. AA attenuated mitochondrial dysfunction and reduced matrix metalloproteinase-9 induction.
Conclusions—Our study shows AA is effective against multiple models of focal ischemia, has a long therapeutic time
window, and is also effective in females and hypertensive animals. AA may mediate neuroprotection by protecting
mitochondria and inhibiting matrix metalloproteinase-9 induction and activation. Taken together these data suggest that
AA is an excellent candidate for development as a stroke therapy. (Stroke. 2012;43:1632-1638.)
Key Words: asiatic acid 䡲 matrix metalloproteinase-9 䡲 mitochondria 䡲 neuroprotective 䡲 stroke

S troke is a leading cause of mortality and the largest single


cause of adult disability worldwide.1 Treatment with
tissue-type plasminogen activator, the only approved pharma-
The Stroke Therapy Academic Industry Roundtable
(STAIR)8 has published recommendations for preclinical
testing of candidate stroke therapies. These recommenda-
cological therapy, is limited by its narrow time window and tions include determining: a dose–response relationship, a
the risk of hemorrhagic complications. A plethora of neuro- therapeutic time window, and efficacy in multiple models
protectants have failed to translate to clinically effective including permanent and transient ischemia, female ani-
therapies and a desperate need exists for new therapies.2 mals, aged animals, and animals with comorbidities. Effi-
Asiatic acid (AA) is a triterpene isolated from Centella cacy in both behavioral and histological time points was
asiatica, which has been widely used as an antioxidant and also recommended.
anti-inflammatory agent.3 AA has also been shown to display Previously, we reported that AA is neuroprotective in a
robust neuroprotective properties both in vitro and in vivo mouse model of permanent focal ischemia and protects the
and shows promise as a novel therapeutic agent for acute integrity of the blood– brain barrier (BBB) after ischemia.7 In
stroke therapy.4 –7 accord with STAIR guidelines, we have now tested AA in

Received September 28, 2011; final revision received January 7, 2012; accepted January 27, 2012.
From the Division of Cerebrovascular Diseases (K.Y.L., O.B., K.S., S.H., A.M., S.B., J.G., M.K., A.M.), Department of Neurology and
Ophthalmology, Department of Pathobiology and Diagnostic Investigation, and Diagnostic Center for Population & Animal Health (S.D.F.), Department
of Epidemiology (M.R.), and Department of Medicine (G.S.), Michigan State University, East Lansing, MI; the College of Pharmacy (O.B.), Hanyang
University, Ansan, Gyeonggido, Korea; the College of Pharmacy (S.B.), Ajou University, Suwon, Gyeonggido, Korea; Veterinary Diagnostic and
Production Animal Medicine (W.R.), College of Veterinary Medicine, Iowa State University, Ames, IA; and the Department of Neurology (A.M.), Salford
Royal Hospital, Salford, UK.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.111.
639427/-/DC1.
Correspondence to Arshad Majid, MD, Department of Neurology, Salford Royal Hospital, Stott Lane, Salford, UK 0161 2064279. E-mail
majidarshad@msn.com
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.639427

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Lee et al AA Protects Against Focal Cerebral Ischemia 1633

multiple stroke models using both histological and functional Experiment 2: Determination of a
outcomes and established a dose–response relationship and a Dose–Response Relationship
therapeutic time window. We also investigated the mecha- We sought to determine the dose–response relationship and the
nism of action and provide evidence of reduced mitochon- therapeutic time window in healthy young males in both pMCAO
and tMCAO models.
drial damage and matrix metalloproteinase inhibition. Male SD rats were randomly assigned to treatment with AA
(50 –75 mg/kg) or vehicle at 30 minutes (AA 50 mg/kg, n⫽21; AA
75 mg/kg, n⫽23; vehicle, n⫽25) before ischemia or 6 (AA 75
Materials and Methods mg/kg, n⫽20; vehicle, n⫽20), 9 (AA 75 mg/kg, n⫽18; vehicle,
n⫽17), and 12 (AA 75 mg/kg, n⫽19; vehicle, n⫽18) hours after
Animals ischemia onset in the pMCAO model.
Adult male Sprague-Dawley (SD), female SD rats, and male spon- Similarly, rats were randomly assigned treatment with AA or
taneously hypertensive rats (SHR) weighing 250 to 300 g were used vehicle at 6 (AA 75 mg/kg, n⫽18; vehicle, n⫽17), 9 (AA 75 mg/kg,
(Harlan, Indianapolis, IN). All experiments were performed in n⫽18; vehicle, n⫽20), or 12 (AA 75 mg/kg, n⫽19; vehicle, n⫽21)
accord with the National Institutes of Health Policy and Animal hours after ischemia onset in the tMCAO model. Infarct volumes
Welfare Act under the approval by Institutional Animal Care and were evaluated at 24 hours after middle cerebral artery occlusion
Use Committee at Michigan State University. (MCAO).

Drugs Experiment 3: Determination of the Influence of


AA was dissolved to a concentration of 50 mg/mL in ubisol-Aqua Gender on Outcomes
(Zymes LLC, Hasbrouck Heights, NJ). The lateral tail vein was used Clinical stroke affects both genders. We sought to determine the
for the administration of AA or ubisol-Aqua (vehicle). influence of gender on outcomes. Female SD rats (9 –10 weeks) were
subjected to pMCAO and treated with AA (75 mg/kg, n⫽11) or
vehicle (n⫽12) at 6 hours after ischemia onset.
Blinding and Randomization
Treatment groups were allocated in a randomized fashion using a Experiment 4: Determination of the Influence of
Researcher Randomizer (www.randomizer.org/). Investigators were
blind to the allocation of treatment when doing surgeries and doing
Hypertension on Outcomes
outcome evaluations. Clinical stroke affects patients with comorbidities like hypertension.
We sought to determine the efficacy of AA in the presence of
hypertension. SHRs were subjected to tMCAO. Only tMCAO was
Justification for the Ischemia Models Used in used because SHRs have very high mortality rates with pMCAO.10
These Studies SHRs were subjected to 1 hour tMCAO and treated with AA (75
There is no ideal stroke model that completely reflects clinical stroke mg/kg, n⫽12) or vehicle (n⫽13) at 6 hours after ischemia onset.
in humans. We used both permanent (pMCAO) and transient Infarct volumes were evaluated at 24 hours after MCAO.
(tMCAO) middle cerebral artery occlusion models using a filament
to occlude the middle cerebral artery through the carotid (see the Experiment 5: Determination of Long-Term
online-only Data Supplement). The pMCAO models the clinical Histological and Behavioral Outcomes
situation of occlusion of the cerebral vessel without recanalization. We sought to determine long-term histological and behavioral
The tMCAO models the recanalization of a previously occluded outcomes. Male SD rats were randomly divided into 3 groups. (Only
cerebral vessel either spontaneously or with treatment.9 Because the transient model was used because like other investigators, we
stroke can involve both situations, we tested both models. also observed high long-term mortality.) The sham group had
surgery but was not subjected to tMCAO (n⫽6). The other 2 groups
were subjected to tMCAO and blindly treated with AA (75 mg/kg,
Experimental Groups n⫽23) or vehicle (n⫽18) at 6 hours after ischemia onset. The
Detailed methods of blood sampling and pharmacokinetics studies, neurological scores, behavioral tests, and infarct volumes were
surgery and induction of ischemia, neurological score, behavioral evaluated during and at the end of 2 weeks post-MCAO.
testing, calculation of infarct volume using triphenyltetrazolium
chloride and cresyl violet staining, brain mitochondrial isolation, Experiment 6: Exploration of Possible Mechanisms
respiration measurements, in vivo matrix metalloproteinase (MMP) of Action
level measurements, and statistical analyses are available in the
We explored possible mechanism of action by examining the effects
online-only Data Supplement. of AA on brain mitochondrial bioenergetics and MMP induction and
activity. Both these mechanisms play a role in ischemic injury.11–13
Experiment 1: Determination of Pharmacokinetics Male SD rats were randomly divided into 2 groups and subjected to
and Safety/Tolerability of AA tMCAO and treated with AA (75 mg/kg, n⫽8) or vehicle (n⫽8) at
We sought to determine pharmacokinetics and safety/tolerability of 6 hours after ischemia onset. The brain tissues were isolated at 24
hours after MCAO for mitochondrial isolation and Western blots.
AA. Male SD rats (9 –10 weeks) were randomly divided into 4
(Details of the tissue isolation are provided in the only-only Data
groups (n⫽7 rats/group) and given a single intravenous bolus
Supplement).
injection of vehicle or 10, 25, and 75 mg/kg AA. Blood samples were
drawn before administration and at 15 minutes, 1 hour, 3 hours, 6
hours, 12 hours, and 24 hours postadministration. The concentration Results
of AA in serum at each time point was measured using high- Safety, Tolerability, and Pharmacokinetics
performance liquid chromatography/mass spectroscopy. Rats were After a single intravenous injection of 10, 25, and 75 mg/kg,
allowed to survive for 14 days. For safety and tolerability evalua- serum concentrations of AA increased to 2.95, 6.16, and
tions, the daily assessment occurred of the following: (1) food
consumption; (2) body weight; (3) activity; and (4) mortality. All
8.62 ␮mol/L, respectively, at 15 minutes. The subsequent fall
animals underwent blood analysis for chemistry and hematology. In in serum concentrations within the first 1 hour was rapid
a separate set of experiments, AA or vehicle was administered to rats (Figure 1). The T1/2 of 75 mg/kg AA was 2.00⫾0.18 hours.
(n⫽4 per group) and blood pressure was monitored for 24 hours. The maximal concentration value and area under the curve
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1634 Stroke June 2012

Figure 1. Serum concentration of AA after an intravenous injec-


tion at 10, 25, and 75 mg/kg. AA indicates asiatic acid.

value of 75 mg/kg AA was 9.70⫾0.82 mg/L and 27.67⫾2.91


mg 䡠 hr/L, respectively (online-only Data Supplement Table
VI). AA was well tolerated up to a dose of 75 mg/kg. Higher
doses could not be tested because of toxicity associated with
the solvent. Food consumption, activity, weight, mean arterial
pressure, heart rate, and mortality are presented in online-
only Data Supplement Figures I through V.

AA Attenuates Infarct Volume After


Ischemic Stroke
Dose–Response Relationship and Therapeutic
Time Window
AA administration (50 or 75 mg/kg, 30 minutes before
MCAO) had a dose-dependent protective effect, attenuating
infarct volume against pMCAO at 24 hours by 37.0% and
52.5%, respectively (Figure 2A). To determine the therapeu-
Figure 2. Protective effect of AA on infarct volume. AA was admin-
tic time window, rats were administered AA (75 mg/kg) at 6,
istrated 30 minutes before ischemia onset in pMCAO (A). AA treat-
9, or 12 hours after onset of ischemia. As illustrated in Figure ments (50 mg/kg and 75 mg/kg) significantly reduced infarct vol-
2B, treatment with AA significantly decreased infarct volume ume compared with the vehicle group. AA (75 mg/kg) was
even 12 hours after pMCAO. In tMCAO, infarct volume was administrated at 6, 9, or 12 hours after ischemia onset in pMCAO
(B) and tMCAO (C) models. Infarct volume was determined at 24
significantly reduced with AA treatment at 6 or 9 hours, hours after MCAO by TTC staining. AA treatment significantly
53.1% and 52.3%, respectively (Figure 2C). reduced infarct volume up to 12 hours postischemia onset. Scale
bar, 1 cm. All values are means⫾SEM and analyzed by 1-way
Efficacy in Female Rats and Hypertensive Rats analysis of variance. *P⬍0.05, **P⬍0.01, ***P⬍0.001 versus vehicle
Additional studies were performed in female animals and group. AA indicates asiatic acid; pMCAO, permanent middle cere-
bral artery occlusion; tMCAO, transient middle cerebral artery
hypertensive animals. As illustrated in Figure 3A, 6 hours occlusion; TTC, triphenyltetrazolium chloride.
posttreatment with AA (75 mg/kg) in female rats decreased
infarct volume by 56.4%. Similarly, AA (75 mg/kg) 6 hours with AA was observed at postoperative Day 14 (repeated-
postischemia in SHR significantly reduced infarct volume by measures analysis of variance, P⫽0.056). Significant im-
25.6% (Figure 3B). provement for the adhesive removal test was observed at
Determination of Long-Term Efficacy of Histological and postoperative Day 14 (P⫽0.027; Figure 4D).
Functional Outcomes
To test whether the neuroprotective effect of AA is sustained, AA Influences Mitochondrial Health and MMPs
AA (75 mg/kg) was administered 6 hours after onset of Influence of AA on Mitochondrial Respiration Functions
ischemia. Neurological function and cerebral infarct volume Brain mitochondrial bioenergetics were characterized by
were determined at 14 days. AA reduced infarct volume by measuring oxygen consumption rates of different substrates
36.3% (Figure 4A). AA treatment also significantly improved and calculating the respiratory control ratio (RCR; Figure 5).
functional outcome and decreased motor, sensory, and reflex The measured rates of oxygen consumption of different
impairment 1, 3, 7, and 14 days after ischemia (Figure 4B). mitochondrial substrates and the derived RCR serve as
Additional functional testing using the adhesive removal and important indicators of mitochondrial respiratory capacity
Rotorod tests were done before (baseline) and 1, 3, 7, and 14 and functional homeostasis.11,12 Adenosine 5⬘-triphosphate
days after ischemia (Figure 4C–D). In the Rotorod test, a phosphorylation (State III) rates were significantly decreased
strong trend toward better performance of the group injected in mitochondria sampled from the ipsilateral hemisphere after
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Lee et al AA Protects Against Focal Cerebral Ischemia 1635

Western blotting. Ischemic rats showed an increase in


MMP-9 levels in the ipsilateral hemisphere, whereas no
changes in MMP-2 were detected (Figure 6A–B). AA treat-
ment significantly inhibited MMP-9 induction (Figure 6C).
To determine whether AA inhibits MMP activity, an in
vitro assay using recombinant MMP-9 was performed. The
MMP-9 was incubated with various concentrations (0.1, 0.5,
and 1 mmol/L) of AA, and the effect on enzyme activity was
determined by the ability to degrade fluorescently labeled
gelatin. AA significantly inhibited MMP-9 (Figure 6D) in a
concentration-dependent manner. Because MMPs are zinc-
dependent endopeptidases, AA inhibitory activity in excess
zinc was examined to determine whether AA has a metal-
chelating effect on zinc. Our results suggest that AA does not
inhibit MMP activity by zinc chelation.

Discussion
We have previously shown in a mouse model of pMCAO that
AA is neuroprotective, has antioxidant activity, and protects
BBB integrity after ischemia.7 The current study, using
rigorous blinding and randomization methodology, has estab-
lished a dose–response relationship and confirmed efficacy in
4 other MCAO stroke models: pMCAO/tMCAO in male rats,
pMCAO in female rats, and tMCAO in SHRs. We also show
that AA has a long and clinically relevant therapeutic time
window. Furthermore, we have identified ischemia-activated
deleterious mechanisms that are favorably influenced by AA.
Several of our findings are particularly noteworthy. First,
AA exhibited significant neuroprotection, even when admin-
istered 12 hours after the onset of ischemia, which could
translate to a clinically long time window for treatment and
will allow the treatment of many more patients. Second,
Figure 3. Effect of AA on infarct volume in female and SHRs. AA because almost half of all strokes affect females and hyper-
(75 mg/kg) was administrated 6 hours after ischemia onset in tension is the biggest risk factor for stroke, efficacy in female
female pMCAO (A) and SHR tMCAO (B) models. Infarct volume
rats and the SHR model strengthens the case for further
was determined at 24 hours after permanent MCAO by TTC
staining. AA treatment significantly reduced infarct volume com- preclinical development. Third, our findings that AA im-
pared with vehicle groups in both female and SHR. Scale bar, 1 proves both histological and functional outcomes 14 days
cm. All values are means⫾SEM and analyzed by 1-way analysis after ischemia suggest sustained benefit.
of variance. *P⬍0.05, **P⬍0.01, ***P⬍0.001 versus vehicle
group. AA indicates asiatic acid; SHRs, spontaneously hyperten- Our pharmacokinetic data suggest that AA has a half-life
sive rats; pMCAO, permanent middle cerebral artery occlusion; of 2.0 hours. This relatively short half-life raises the possi-
tMCAO, transient middle cerebral artery occlusion; MCAO, mid- bility that maintaining serum levels of AA for longer periods
dle cerebral artery occlusion; TTC, triphenyltetrazolium chloride. of time by using multiple dosing or bolus plus infusion
regimens may afford greater efficacy. Future studies will
MCAO (Figure 5A). AA treatment restored State III. The explore multiple dosing strategies to determine if there is
RCR (State III respiration divided by State IV respiration) is greater efficacy using those regimens. It is also possible that
an index of how coupled the electron transport chain is to multiple dosing regimens may allow smaller doses to be
adenosine 5⬘-triphosphate production. Figure 5B shows alter- administered.
ations in RCR values after ischemia injury in both the AA favorably influences a number of deleterious mecha-
ipsilateral (injured) hemisphere and contralateral (uninjured) nisms that are activated after stroke.2 We have previously
hemisphere. After MCAO, RCR was significantly attenuated shown that AA is a powerful antioxidant and also that it
in the ischemic cortex sample by 69.8%. AA treatment maintains the integrity of the BBB after ischemia.7 We have
decreased the attenuation of RCR by 42.8%. now extended our mechanistic studies to include the influ-
ence of AA on mitochondrial redox activity and MMP
Influence of AA on MMPs induction and enzymatic activity and show that AA also
The MMPs are induced in the brain after ischemia and are favorably influences these pathways. The postischemic brain
involved in disruption of the BBB among other deleterious exhibits prominent changes in redox activity of mitochondrial
processes.13 To determine whether AA treatment could in- respiratory chain components.14 –16 Mitochondria isolated
hibit MMP activity in the brain after ischemia, the levels of from ischemic brains exhibited decreases in State III respira-
MMP-2 and MMP-9 protein in the brain were determined by tory rates of approximately 70% with nicotinamide-adenine
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1636 Stroke June 2012

Figure 4. Improvement of long-term histological


and neurological functional outcomes after tMCAO.
AA (75 mg/kg) or vehicle were administered at 6
hours after ischemia onset. Infarct volume was
determined at 14 days after 2 hours tMCAO by
Nissl staining (A). AA treatment significantly
reduced infarct volume and improved functional
outcome. B, Neurological scores. C, Rotorod test.
D, Adhesive tape removal test at the right. AA
decreased motor, sensory, and reflex functional
damage after 2 hours tMCAO determined at 1, 3,
7, and 14 days after ischemia by neurological defi-
cit scoring (0 –18). The adhesive removal and
Rotorod tests were done both before (baseline)
and 1, 3, 7, and 14 days after ischemia. There was
a strong trend toward better performance of the
AA-treated animals (white circle) in both Rotorod
and adhesive tape removal tests. Scale bar, 1 cm.
All values are means⫾SEM and analyzed by 1-way
analysis of variance. *P⬍0.05, **P⬍0.01,
***P⬍0.001 versus vehicle group. tMCAO indicates
transient middle cerebral artery occlusion; AA, asi-
atic acid.

dinucleotide-linked respiratory substrates.17 In the current expression and activity have been demonstrated in the ische-
study, we confirm previous studies that showed that reperfu- mic brain.23,24 MMP inhibitors and MMP-9 gene deletion
sion after cerebral ischemia resulted in mitochondrial dam- attenuated BBB disruption and brain tissue infarction after
age.18 –20 Our data show that AA inhibited ischemia induced ischemia.25,26 Clinical studies have also shown a correlation
reductions of RCR, the index of mitochondrial respiratory between plasma MMP-9 levels and the rate of hemorrhagic
function indicating that AA protects mitochondria during transformation in human stroke.27 In the present study, we
ischemia. confirmed that MMP-9 expression was increased after ische-
MMPs degrade the extracellular matrix and are involved in mia and showed that AA treatment attenuated the increase in
several brain diseases including stroke.21,22 Enhanced MMP-9 MMP-9. It is, however, possible that the attenuation in

Figure 5. Mitochondrial bioenergetics after tMCAO. A, Representative traces from nonsynaptic mitochondrial oxygen consumption measurements
in the presence of oxidative substrates (pyruvate and malate), ADP, oligomycin, CCCP, and succinate. B, The respiratory control ratios (RCR), which
is State III respiration divided by State IV respiration. Data were expressed as mean⫾SEM. *P⬍0.05, **P⬍0.01 versus contra group; #P⬍0.05,
##P⬍0.01 versus vehicle group. Contra indicates contralateral hemisphere; ipsil, ipsilateral hemisphere; tMCAO, transient middle cerebral artery
occlusion; ADP, adenosine 5⬘diphosphate; CCCP, carbonylcyanide m-chlorophenylhydrazone.

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Lee et al AA Protects Against Focal Cerebral Ischemia 1637

Figure 6. Effects of AA on MMP-2 and


MMP-9. A, Western blot showing MMP-9
expression in the brain is enhanced after
ischemia in the ipsilateral hemisphere in
rats receiving vehicle (Lane 2), but this
effect is attenuated by AA (Lane 4).
MMP-2 levels were unchanged (␤-actin
illustrates protein loading in different lanes
for MMP-9 and MMP-2). B, MMP-2. C,
MMP-9. AA inhibited MMP-9 activity in
vitro regardless of excess ZnCl2. D,
MMP09. Data were expressed as
mean⫾SEM *P⬍0.05, **P⬍0.01 versus
contra group; #P⬍0.05, ##P⬍0.01,
###P⬍0.001 versus vehicle group. Contra
indicates contralateral hemisphere; ipsil,
ipsilateral hemisphere; AA, asiatic acid;
MMP, matrix metalloproteinase.

MMP-9 induction may be due to the smaller infarct volume Disclosures


rather than the direct affect of AA on MMP induction. Our in None.
vitro data on the other hand show that AA inhibits MMP
enzyme activity. The mechanism through which AA inhibits References
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Asiatic Acid Attenuates Infarct Volume, Mitochondrial Dysfunction, and Matrix
Metalloproteinase-9 Induction After Focal Cerebral Ischemia
Ki Yong Lee, Ok-Nam Bae, Kelsey Serfozo, Siamk Hejabian, Ahmad Moussa, Mathew Reeves,
Wilson Rumbeiha, Scott D. Fitzgerald, Gary Stein, Seung-Hoon Baek, John Goudreau, Mounzer
Kassab and Arshad Majid

Stroke. 2012;43:1632-1638; originally published online April 17, 2012;


doi: 10.1161/STROKEAHA.111.639427
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