Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2020 Feb 19;2(2):CD010722.
doi: 10.1002/14651858.CD010722.pub2.

Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke

Alessia Mattioni  1 , Silvia Cenciarelli  1 , Paolo Eusebi  2 , Miriam Brazzelli  3 , Tatiana Mazzoli  1 , Massimo Del Sette  4 , Carlo Gandolfo  5 , Marinella Marinoni  6 , Cinzia Finocchi  5 , Valentina Saia  7 , Stefano Ricci  1
Affiliations
Meta-Analysis

Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke

Alessia Mattioni et al. Cochrane Database Syst Rev. .

Abstract

Background: An occlusion or stenosis of intracranial large arteries can be detected in the acute phase of ischaemic stroke in about 42% of patients. The approved therapies for acute ischaemic stroke are thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy; both aim to recanalise an occluded intracranial artery. The reference standard for the diagnosis of intracranial stenosis and occlusion is intra-arterial angiography (IA) and, recently, computed tomography angiography (CTA) and magnetic resonance angiography (MRA), or contrast-enhanced MRA. Transcranial Doppler (TCD) and transcranial colour Doppler (TCCD) are useful, rapid, noninvasive tools for the assessment of intracranial large arteries pathology. Due to the current lack of consensus regarding the use of TCD and TCCD in clinical practice, we systematically reviewed the literature for studies assessing the diagnostic accuracy of these techniques compared with intra-arterial IA, CTA, and MRA for the detection of intracranial stenosis and occlusion in people presenting with symptoms of ischaemic stroke.

Objectives: To assess the diagnostic accuracy of TCD and TCCD for detecting stenosis and occlusion of intracranial large arteries in people with acute ischaemic stroke.

Search methods: We limited our searches from January 1982 onwards as the transcranial Doppler technique was only introduced into clinical practice in the 1980s. We searched MEDLINE (Ovid) (from 1982 to 2018); Embase (Ovid) (from 1982 to 2018); Database of Abstracts of Reviews of Effects (DARE); and Health Technology Assessment Database (HTA) (from 1982 to 2018). Moreover, we perused the reference lists of all retrieved articles and of previously published relevant review articles, handsearched relevant conference proceedings, searched relevant websites, and contacted experts in the field.

Selection criteria: We included all studies comparing TCD or TCCD (index tests) with IA, CTA, MRA, or contrast-enhanced MRA (reference standards) in people with acute ischaemic stroke, where all participants underwent both the index test and the reference standard within 24 hours of symptom onset. We included prospective cohort studies and randomised studies of test comparisons. We also considered retrospective studies eligible for inclusion where the original population sample was recruited prospectively but the results were analysed retrospectively.

Data collection and analysis: At least two review authors independently screened the titles and abstracts identified by the search strategies, applied the inclusion criteria, extracted data, assessed methodological quality (using QUADAS-2), and investigated heterogeneity. We contacted study authors for missing data.

Main results: A comprehensive search of major relevant electronic databases (MEDLINE and Embase) from 1982 to 13 March 2018 yielded 13,534 articles, of which nine were deemed eligible for inclusion. The studies included a total of 493 participants. The mean age of included participants was 64.2 years (range 55.8 to 69.9 years). The proportion of men and women was similar across studies. Six studies recruited participants in Europe, one in south America, one in China, and one in Egypt. Risk of bias was high for participant selection but low for flow, timing, index and reference standard. The summary sensitivity and specificity estimates for TCD and TCCD were 95% (95% CI = 0.83 to 0.99) and 95% (95% CI = 0.90 to 0.98), respectively. Considering a prevalence of stenosis or occlusion of 42% (as reported in the literature), for every 1000 people who receive a TCD or TCCD test, stenosis or occlusion will be missed in 21 people (95% CI = 4 to 71) and 29 (95% CI = 12 to 58) will be wrongly diagnosed as harbouring an intracranial occlusion. However, there was substantial heterogeneity between studies, which was no longer evident when only occlusion of the MCA was considered, or when the analysis was limited to participants investigated within six hours. The performance of either TCD or TCCD in ruling in and ruling out a MCA occlusion was good. Limitations of this review were the small number of identified studies and the lack of data on the use of ultrasound contrast medium.

Authors' conclusions: This review provides evidence that TCD or TCCD, administered by professionals with adequate experience and skills, can provide useful diagnostic information for detecting stenosis or occlusion of intracranial vessels in people with acute ischaemic stroke, or guide the request for more invasive vascular neuroimaging, especially where CT or MR-based vascular imaging are not immediately available. More studies are needed to confirm or refute the results of this review in a larger sample of stroke patients, to verify the role of contrast medium and to evaluate the clinical advantage of the use of ultrasound.

PubMed Disclaimer

Conflict of interest statement

Alessia Mattioni: none Silvia Cenciarelli: none Paolo Eusebi: none Miriam Brazzelli: none Tatiana Mazzoli: none Massimo Del Sette: none Carlo Gandolfo: none Marinella Marinoni: none Cinzia Finocchi: none Valentina Saia: none Stefano Ricci: none

Figures

1
1
Possible role of TCD/TCCD in the current stroke care pathway
2
2
Study flow diagram.
3
3
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
4
4
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
5
5
Forest plot of paired sensitivity and specificity estimated for studies assessing stenosis or occlusion in any intracranial artery with either TCD or TCCD as index test.
6
6
Summary ROC plot for studies assessing stenosis or occlusion in any intracranial artery with either TCD or TCCD as index test.
7
7
Forest plot of paired sensitivity and specificity estimates for studies assessing stenosis or occlusion in the middle cerebral artery with either TCD or TCCD as index test.
8
8
Summary ROC plot for studies assessing stenosis or occlusion in the middle cerebral artery with either TCD or TCCD as index test.
1
1. Test
TCD/TCCD (any artery).
4
4. Test
TCD/TCCD (MCA).
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010722

References

References to studies included in this review

Bar 2010 {published data only}
    1. Bar M, Skoloudik D, Roubec M, Hradiek P, Chmelovà J, Czerny D, et al. Transcranial Duplex sonography and CT angiography in acute stroke patients. Journal of Neuroimaging 2010;20:240‐5. - PubMed
Brunser 2009 {published data only}
    1. Brunser AM, Lavados PM, Hoppe A, Lopez J, Valenzuela M, Rivas R. Accuracy of transcranial Doppler compared with CT angiography in diagnosing arterial obstructions in acute ischemic strokes. Stroke 2009;40:2037‐41. - PubMed
Camerlingo 1993 {published data only}
    1. Camerlingo M, Casto L, Censori B, Ferraro B, Gazzaniga GC, Mamoli A. Transcranial doppler in acute ischemic stroke of the middle cerebral artery territories. Acta Neurologica Scandinavica 1993;88:108‐11. - PubMed
Guan 2013 {published data only}
    1. Guan J, Zhou Q, Ouyang H, Zhang S, Lu Z. The diagnostic accuracy of TCD for intracranial arterial stenosis/occlusion in patients with acute ischemic stroke: the importance of time interval between detection of TCD and CTA. Neurological Research 2013;35(9):930‐6. - PubMed
Kamel 2010 {published data only}
    1. Kamel A, Aziz SA, El‐Ebyary MM, El‐Fattah DA, Shawky KM. Ischemic stroke of anterior circulation: sensitivity and prognostic value of early ultrasound and imaging studies. Egyptian Journal of Neurology, Psychiatry and Neurosurgery 2010;47(2):303‐10.
Kenton 1997 {published data only}
    1. Kenton AR, Martin PJ, Abbott RJ, Moody AR. Comparison of transcranial color‐coded sonography and magnetic resonance angiography in acute stroke. Stroke 1997;28:1601‐6. - PubMed
Martinez‐Sanchez 2015 {published data only}
    1. Martinez‐Sanchez P, Garcia‐Pastor A, Arenillas‐Lara JF, Ayo‐Martin O, Ruiz‐Ares G, Diaz‐Otero F, et al. Accuracy of transcranial duplex sonography, compared with CT angiography, for detection of intracranial arterial occlusions in acute stroke. International Journal of Stroke 2015;10 Suppl 2:77‐438.
Panebianco 2016 {published data only}
    1. Panebianco M, Zavanone C, Perrone P, Callone MV. Transcranial color doppler ultrasonography: the "stethoscope" of vascular neurologist for assessment of medium cerebral artery in acute ischemic stroke patients. Conference proceeding ‐ Congresso Nazionale SNO 2016, Catania, Italy.
Zanette 1989 {published data only}
    1. Zanette EM, Fieschi C, Bozzao L, Roberti C, Toni D, Argentino C, et al. Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke. Stroke 1989;20:899‐903. - PubMed

References to studies excluded from this review

Bang 2003a {published data only}
    1. Bang OY, Joo IS, Huh K, Kim SY. The role of transcranial Doppler in symptomatic striatocapsular small deep infarction. Journal of Neuroimaging 2003;13(1):48‐52. - PubMed
Bang 2003b {published data only}
    1. Bang OY, Cho JH, Han BI, Joo IS, Kim DI, Huh K. Transcranial Doppler findings in middle cerebral arterial occlusive disease in relation to degree of stenosis and presence of concomitant stenoses. Journal of Clinical Ultrasound 2003;31(3):142‐51. - PubMed
Barlinn 2013 {published data only}
    1. Barlinn K, Zivanovic Z, Zhao l, Kesani M, Balucani C, Tsivgoulis G, et al. Intracranial vessel localization with power motion Doppler (PMD‐TCD) compared with CT angiography in patients with acute ischaemic stroke. International Journal of Stroke 2013;8(6):398‐402. - PubMed
Chen 2014 {published data only}
    1. Chen J, Wang L, Bai J, Lun Z, Zhang J, Xing Y. The optimal velocity criterion in the diagnosis of unilateral middle cerebral artery stenosis by transcranial Doppler. Cell Biochemisty and Biophysics 2014;69(1):81‐7. - PubMed
Felberg 2002 {published data only}
    1. Felberg RA, Christou I, Demchuk AM, Malkoff M, Alexandrov AV. Screening for intracranial stenosis with transcranial Doppler: the accuracy of mean flow velocity thresholds. Journal of Neuroimaging 2002;12(1):9‐14. - PubMed
Gerriets 2002 {published data only}
    1. Gerriets T, Goertler M, Stolz E, Postert T, Sliwka U, Schlachetzki F, et al. Feasibility and validity of transcranial duplex sonography in patients with acute stroke. Journal of Neurology, Neurosurgery and Psychiatry 2002;73(1):17‐20. - PMC - PubMed
Khan 2009 {published data only}
    1. Khan S, Rich P, Clifton A, Markus HS. Noninvasive detection of vertebral artery stenosis: a comparison of contrast‐enhanced MR angiography, CT angiography, and ultrasound. Stroke 2009;40(11):3499‐503. - PubMed
Kim 2014 {published data only}
    1. Kim JS, Lee SW, Eun MY, Seo WK. Power motion‐mode Doppler signature: a useful tool for assessing middle cerebral artery stenosis. Journal of Clinical Ultrasound 2014;42(6):348‐54. - PubMed
Lange 2015 {published data only}
    1. Lange MC, Bruch TP, Pedrozo JC, Maranha L, Sakae TM, Pacheco R, et al. The use of neurovascular ultrasound versus digital subtraction angiography in acute ischemic stroke. Arquivos de Neuro‐Psiquiatria 2015;73(3):218‐22. - PubMed
Ley‐Pozo 1990 {published data only}
    1. Ley‐Pozo J, Ringelstein EB. Noninvasive detection of occlusive disease of the carotid siphon and middle cerebral artery. Annals of Neurology 1990;28(5):640‐7. - PubMed
Nasr 2013 {published data only}
    1. Nasr N, Ssi‐Yan‐Kai G, Guidolin B, Bonneville F, Larrue V. Transcranial color‐coded sonography to predict recurrent transient ischaemic attack/stroke. European Journal of Neurology 2013;20(8):1212‐7. - PubMed
Postert 1998 {published data only}
    1. Postert T, Braun B, Federlein J, Przuntek H, Köster O, Büttner T. Diagnosis and monitoring of middle cerebral artery occlusion with contrast‐enhanced transcranial color‐coded real‐time sonography in patients with inadequate acoustic bone windows. Ultrasound in Medicine and Biology 1998;24(3):333‐40. - PubMed
Postert 1999 {published data only}
    1. Postert T, Braun B, Meves S, Köster O, Przuntek H, Weber S, et al. Contrast‐enhanced transcranial color‐coded sonography in acute hemispheric brain infarction. Stroke 1999;30(9):1819‐26. - PubMed
Rorick 1994 {published data only}
    1. Rorick MB, Nichols FT, Adams RJ. Transcranial Doppler correlation with angiography in detection of intracranial stenosis. Stroke 1994;25(10):1931‐4. - PubMed
Suwanwela 2002 {published data only}
    1. Suwanwela NC, Phanthumchinda K, Suwanwela N. Transcranial doppler sonography and CT angiography in patients with atherothrombotic middle cerebral artery stroke. American Journal of Neuroradiology 2002;23(8):1352‐5. - PMC - PubMed
Tsivgoulis 2007 {published data only}
    1. Tsivgoulis G, Sharma VK, Lao AY, Malkoff MD, Alexandrov AV. Validation of transcranial Doppler with computed tomography angiography in acute cerebral ischemia. Stroke 2007;38(4):1245‐9. - PubMed
Zhou 2013 {published data only}
    1. Zhou C, Zhang Pl. Comparative study of transcranial Doppler ultrasonography and magnetic resonance angiography on recanalization of intravenous thrombolysis with alteplase in acute ischemic stroke patients. Chinese Journal of Contemporary Neurology and Neurosurgery 2013;13(12):1027‐32.

References to ongoing studies

Palmieri 2017 {published data only}
    1. Palmieri A, Farina FM, Kulyk C, Viaro F, Baracchini C, Vodret FR, et al. Accuracy of transcranial colorcoded duplex sonography in the diagnosis of acute intracranial large vessel occlusion. International Journal of Stroke 2017;12(1 Supplement 1):18.

Additional references

Adams 2007
    1. Adams HP, Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke. A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Circulation 2007;115:e478‐e534. - PubMed
Alexandrov 1999
    1. Alexandrov AV, Demchuk AM, Wein TH, Grotta JC. Yield of transcranial doppler in acute cerebral ischemia. Stroke 1999;30:1604‐9. - PubMed
Allendoerfer 2006
    1. Allendoerfer J, Goertler M, Reutern GM, Neurosonology in Acute Ischemic Stroke Study Group. Prognostic relevance of ultra‐early doppler sonography in acute ischaemic stroke: a prospective multicentre study. Lancet Neurology 2006;5:835‐40. - PubMed
Arnold 2004
    1. Arnold M, Nedeltchev K, Brekenfeld C, Fischer U, Remonda L, Schroth G, et al. Outcome of acute stroke patients without visible occlusion on early arteriography. Stroke 2004;35:1135‐8. - PubMed
Astin 2008
    1. Astin M, Brazzelli M, Fraser C, Counsell C, Needham G, Grimshaw J. Developing a sensitive search strategy in MEDLINE to retrieve studies on assessment of the diagnostic performance of imaging techniques. Radiology 2008;247:365‐73. - PubMed
Baracchini 2016
    1. Baracchini C, Anzola GP, Cenciarelli S, Diomedi M, Bella R, Tono A, et al. Italian symptomatic intracranial atherosclerosis study (ISIDE). Neurological Sciences 2016;37(10):1645‐51. - PubMed
Baracchini 2017
    1. Baracchini C, Viaro F, Favaretto S, Palmieri A, Kulyk C, Causin F, et al. Safety and tolerability of SonoVue® in patients with large artery anterior circulation acute stroke. Journal of Neuroimaging 2017; Vol. 27, issue 4:409‐13. - PubMed
De Vet 2008
    1. Vet HCW, Eisinga A, Riphagen II, Aertgeerts B, Pewsner D. Chapter 7: Searching for studies. In: Deeks JJ, Bossuyt PM, Gatsonis C, editor(s). Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 0.4 [updated September 2008]. The Cochrane Collaboration, 2008. Available from srdta.cochrane.org.
ESO Guidelines 2008
    1. The European Stroke Organisation (ESO) Executive Committee and the ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular Diseases 2008;25:457–507. - PubMed
Fiebach 2012
    1. Fiebach JB, Al‐Rawi Y, Wintermark M, Furlan AJ, Rowley HA, Lindsten A, et al. Vascular occlusion enables selecting acute ischemic stroke patients for treatment with desmoteplase. Stroke 2012;43:1561‐6. - PubMed
Gerriets 2000
    1. Gerriets T, Postert T, Goertler M, Stolz E, Schlachetzki F, Sliwka U, the DIAS (Duplex Sonography in Acute Stroke) Study Group. DIAS I: Duplex‐sonographic assessment of the cerebrovascular status in acute stroke. A useful tool for future stroke trials. Stroke 2000;31:2342‐5. - PubMed
Hankey 1990
    1. Hankey GJ, Warlow CP, Molyneux AJ. Complications of cerebral angiography for patients with mild carotid territory ischaemia being considered for carotid endarterectomy. Journal of Neurology, Neurosurgery and Psychiatry 1990;53:542‐8. - PMC - PubMed
Kassem‐Moussa 2002
    1. Kassen‐Moussa H, Graffagnino C. Nonocclusion and spontaneous recanalization rates in acute ischemic stroke. Archives of Neurology 2002;59:1870‐3. - PubMed
Latchaw 2009
    1. Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 2009;40:3646‐78. - PubMed
Leeflang 2014
    1. Leeflang MMG. Systematic reviews and meta‐analyses of diagnostic test accuracy. Clinical Microbiology and Infection 2014;20(2):105‐13. - PubMed
Macaskill 2010
    1. Macaskill P, Gatsonis C, Deeks J, Harbord R, Takwoingi Y. Chapter 10 Analysing and presenting results. In: Deeks JJ, Harbord RM, Takwoingi Y. Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. Version 1.0. The Cochrane Collaboration, 2010. Available from http://srdt.cochrane.org/.
Mazya 2018
    1. Mazya MV, Ahmed N, Azevedo E, Davalos A, Dorado L, Karlinski M, the SITS Investigators. Impact of transcranial doppler ultrasound on logistics and outcomes in stroke thrombolysis. Results from the SITS‐ISTR. Stroke 2018;49(7):1695‐700. - PubMed
Nacu 2017
    1. Nacu A, Kvistad CE, Naess H, Øygarden H, Logallo N, Assmus J, et al. NOR‐SASS (Norwegian Sonothrombolysis in Acute Stroke Study). Randomized controlled contrast‐enhanced sonothrombolysis in an unselected acute ischemic stroke population. Stroke 2017;48(2):335‐41. - PMC - PubMed
Reference Manager 10 [Computer program]
    1. ISI ResearchSoft. Reference Manager. Version Professional, 10. ISI ResearchSoft, 1984‐2001.
Reitsma 2005
    1. Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. Journal of Clinical Epidemiology 2005;58(10):982‐90. - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, Cochrane Collaboration. Review Manager 5 (RevMan5). Version 5.3. Copenhagen: The Nordic Cochrane Centre, Cochrane Collaboration, 2014.
Ricci 2012
    1. Ricci S, Dinia L, Sette M, Anzola P, Mazzoli T, Cenciarelli S, et al. Sonothrombolysis for acute ischaemic stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. [DOI: 10.1002/14651858.CD008348.pub3] - DOI - PubMed
Rodrigues 2016
    1. Rodrigues FB, Neves JB, Caldeira D, Ferron JM, Ferreira JJ, Costa J. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta‐analysis. BMJ 2016;353:i1754. - PMC - PubMed
Smith 2006
    1. Smith WS, Tsao JW, Billings ME, Johnston C, Hemphill JC, Bonovich DC, et al. Prognostic significance of angiographically confirmed large vessel intracranial occlusion in patients presenting with acute brain ischemia. Neurocritical Care 2006;4:14‐7. - PubMed
SPREAD 2016
    1. Gruppo SPREAD. Stroke PRevention and Educational Awareness Diffusion (SPREAD). VIII Edizione. Ictus cerebrale: linee guida italiane di prevenzione e trattamento. Linee Guida ISO SPREAD 21 luglio 2016 http://www.iso‐spread.it/.
Takwoingi 2017
    1. Takwoingi Y, Guo B, Riley RD, Deeks JJ. Performance of methods for meta‐analysis of diagnostic test accuracy with few studies or sparse data. Statistical Methods in Medical Research 2017;26(4):1896‐911. - PMC - PubMed
Wardlaw 2012
    1. Wardlaw JM, Murray V, Berge E, Zoppo G, Sandercock P, Lindley RL, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta‐analysis. Lancet 2012;379:2364‐72. - PMC - PubMed
Wardlaw 2014
    1. Warldlaw JM, Carpenter T, Sakka E, Mair G, Cohen G, Shuler K, et al. Imaging perfusion deficits, arterial patency and thrombolysis safety and efficacy in acute ischaemic stroke. An observational study of the effect of advanced imaging methods in the Third International Stroke Trial (IST‐3), a randomised controlled trial. Efficacy and Mechanism Evaluation, No. 1.1. Vol. 1, Southampton, UK: NIHR Journals Library, 2014. [DOI: 10.3310/eme01010] - DOI - PubMed
Wardlaw 2015
    1. Wardlaw JM, Dennis MS. Thrombectomy for acute ischemic stroke. JAMA 2015;314(17):1803‐5. - PubMed
Warlow 2003
    1. Warlow C, Sudlow C, Dennis M, Wardlaw J, Sandercock P. Stroke. Lancet 2003;362:1211‐24. - PubMed
Whiting 2011
    1. Whiting PF, Rutjes AWS, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, the QUADAS‐2 Group. QUADAS‐2: a revised tool for the quality assessment of diagnostic accuracy studies. Annals of Internal Medicine 2011;155:529‐36. - PubMed
Yarbrough 2015
    1. Yarbrough CK, Ong CJ, Beyer AB, Lipsey K, Derdeyn CP. Endovascular thrombectomy for anterior circulation stroke. Systematic review and meta‐analysis. Stroke 2015;46:3177‐83. - PubMed

References to other published versions of this review

Mattioni 2013
    1. Mattioni A, Brazzelli M, Cenciarelli S, Mazzoli T, Sette M, Gandolfo C, et al. Transcranial Doppler sonography for detecting stenosis or occlusion of intracranial arteries in people with acute ischaemic stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. [DOI: 10.1002/14651858.CD010722] - DOI - PMC - PubMed

Publication types

MeSH terms