{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T08:50:17Z","timestamp":1782377417900,"version":"3.54.5"},"reference-count":29,"publisher":"Springer Science and Business Media LLC","issue":"3","license":[{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T00:00:00Z","timestamp":1777593600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Henan Province Medical Science and Technology Research Project","award":["LHGJ20240880"],"award-info":[{"award-number":["LHGJ20240880"]}]},{"name":"Henan Province Medical Science and Technology Research Project","award":["LHG20230712"],"award-info":[{"award-number":["LHG20230712"]}]},{"name":"Henan Provincial Science and Technology Research Program","award":["242102310048"],"award-info":[{"award-number":["242102310048"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Transl. Stroke Res."],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Branch atheromatous disease (BAD), a subtype of acute ischemic stroke (AIS), is associated with a high risk of early neurological deterioration (END) and poor prognosis. Wake-up stroke (WUS), comprising 20%\u201330% of AIS cases, is typically excluded from thrombolysis because of unknown onset time. Using diffusion-weighted imaging\/fluid-attenuated inversion recovery (DWI\/FLAIR) mismatch, we evaluated the efficacy and safety of Tenecteplase (TNK) thrombolysis in patients with BAD-related WUS.\u00a0We retrospectively recruited 1,062 patients from seven Zhengzhou hospitals between January 2021 and June 2025. The patients received either TNK (n\u2009=\u2009338) or dual antiplatelet therapy (n\u2009=\u2009724). Propensity score matching (PSM; 1:1, caliper 0.02) yielded 292 matched pairs. Early neurological changes were evaluated using the National Institutes of Health Stroke Scale (NIHSS), and 90-day outcomes were evaluated using the modified Rankin Scale (mRS).\u00a0After PSM, TNK significantly reduced the risk of END (odds ratio [OR]\u2009=\u20090.425, 95% confidence interval [CI]: 0.262\u20130.689; P\u2009&lt;\u20090.001). Patients treated with TNK were more likely to achieve good functional outcomes (modified Rankin Scale [mRS] 0\u20131 and 0\u20132) with fewer poor outcomes (mRS\u2009\u2265\u20094). There were no significant differences in symptomatic intracranial hemorrhage, other bleeding events, or mortality among the groups.\u00a0DWI\/FLAIR mismatch-guided TNK thrombolysis appears to overcome the limitations of an unknown onset time in WUS and may counteract the progressive pathophysiology of BAD.\u00a0TNK intravenous thrombolysis may be a safe and effective treatment for patients with wake-up BAD and DWI\/FLAIR mismatches.<\/jats:p>","DOI":"10.1007\/s12975-026-01443-8","type":"journal-article","created":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T02:58:49Z","timestamp":1777604329000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Efficacy and Safety of Intravenous Thrombolysis with Tenecteplase in Patients with Wake-Up Branch Atheromatous Disease"],"prefix":"10.1007","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-6653-6065","authenticated-orcid":false,"given":"Lili","family":"Zhu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-2330-3352","authenticated-orcid":false,"given":"Ying","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-5338-4358","authenticated-orcid":false,"given":"Jiarong","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1187-9666","authenticated-orcid":false,"given":"Liang","family":"Song","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2298-7953","authenticated-orcid":false,"given":"Haoran","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-7825-6233","authenticated-orcid":false,"given":"Yang","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-5293-9673","authenticated-orcid":false,"given":"Lijuan","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-5732-7526","authenticated-orcid":false,"given":"Shaolei","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7198-0628","authenticated-orcid":false,"given":"Xiaofei","family":"Gao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-6678-1657","authenticated-orcid":false,"given":"Weifeng","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-2317-0597","authenticated-orcid":false,"given":"Guo","family":"Rui","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4500-7508","authenticated-orcid":false,"given":"Haiqiang","family":"Qin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-5265-6473","authenticated-orcid":false,"given":"Mingbo","family":"Tian","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-9937-1676","authenticated-orcid":false,"given":"Shengqi","family":"Fu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,1]]},"reference":[{"key":"1443_CR1","doi-asserted-by":"publisher","first-page":"169","DOI":"10.4103\/bc.bc_56_22","volume":"8","author":"H Duan","year":"2022","unstructured":"Duan H, Yun HJ, Geng X, Ding Y. Branch atheromatous disease and treatment. Brain Circ. 2022;8:169\u201371. https:\/\/doi.org\/10.4103\/bc.bc_56_22.","journal-title":"Brain Circ"},{"key":"1443_CR2","doi-asserted-by":"publisher","first-page":"701","DOI":"10.5551\/jat.RV22003","volume":"30","author":"I Deguchi","year":"2023","unstructured":"Deguchi I, Takahashi S. Pathophysiology and optimal treatment of intracranial branch atheromatous disease. J Atheroscler Thromb. 2023;30:701\u20139. https:\/\/doi.org\/10.5551\/jat.RV22003.","journal-title":"J Atheroscler Thromb"},{"key":"1443_CR3","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2023-076161","volume":"389","author":"R Sharma","year":"2025","unstructured":"Sharma R, Lee K. Advances in treatments for acute ischemic stroke. BMJ. 2025;389:e076161. https:\/\/doi.org\/10.1136\/bmj-2023-076161.","journal-title":"BMJ"},{"key":"1443_CR4","doi-asserted-by":"publisher","first-page":"1087","DOI":"10.1016\/S1474-4422(24)00377-6","volume":"23","author":"KW Muir","year":"2024","unstructured":"Muir KW, Ford GA, Ford I, Wardlaw JM, McConnachie A, Greenlaw N, et al. Tenecteplase versus alteplase for acute stroke within 4\u00b75 h of onset (attest-2): a randomised, parallel group, open-label trial. Lancet Neurol. 2024;23:1087\u201396. https:\/\/doi.org\/10.1016\/S1474-4422(24)00377-6.","journal-title":"Lancet Neurol"},{"key":"1443_CR5","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1016\/S0140-6736(22)01054-6","volume":"400","author":"BK Menon","year":"2022","unstructured":"Menon BK, Buck BH, Singh N, Deschaintre Y, Almekhlafi MA, Coutts SB, et al. Intravenous tenecteplase compared with alteplase for acute ischaemic stroke in Canada (act): a pragmatic, multicentre, open-label, registry-linked, randomised, controlled, non-inferiority trial. Lancet. 2022;400:161\u20139. https:\/\/doi.org\/10.1016\/S0140-6736(22)01054-6.","journal-title":"Lancet"},{"key":"1443_CR6","doi-asserted-by":"publisher","DOI":"10.1016\/j.smrv.2019.101212","volume":"48","author":"L Peter-Derex","year":"2019","unstructured":"Peter-Derex L, Derex L. Wake-up stroke: from pathophysiology to management. Sleep Med Rev. 2019;48:101212. https:\/\/doi.org\/10.1016\/j.smrv.2019.101212.","journal-title":"Sleep Med Rev"},{"key":"1443_CR7","doi-asserted-by":"publisher","first-page":"1574","DOI":"10.1016\/S0140-6736(20)32163-2","volume":"396","author":"G Thomalla","year":"2020","unstructured":"Thomalla G, Boutitie F, Ma H, Koga M, Ringleb P, Schwamm LH, et al. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet. 2020;396:1574\u201384. https:\/\/doi.org\/10.1016\/S0140-6736(20)32163-2.","journal-title":"Lancet"},{"key":"1443_CR8","doi-asserted-by":"publisher","first-page":"194","DOI":"10.1016\/j.jocn.2016.04.011","volume":"33","author":"MG Park","year":"2016","unstructured":"Park MG, Oh EH, Kim BK, Park KP. Intravenous tissue plasminogen activator in acute branch atheromatous disease: does it prevent early neurological deterioration? J Clin Neurosci. 2016;33:194\u20137. https:\/\/doi.org\/10.1016\/j.jocn.2016.04.011.","journal-title":"J Clin Neurosci"},{"key":"1443_CR9","doi-asserted-by":"publisher","first-page":"e168","DOI":"10.1016\/j.jstrokecerebrovasdis.2012.10.012","volume":"22","author":"I Deguchi","year":"2013","unstructured":"Deguchi I, Hayashi T, Kato Y, Nagoya H, Ohe Y, Fukuoka T, et al. Treatment outcomes of tissue plasminogen activator infusion for branch atheromatous disease. J Stroke Cerebrovasc Dis. 2013;22:e168-72. https:\/\/doi.org\/10.1016\/j.jstrokecerebrovasdis.2012.10.012.","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"1443_CR10","doi-asserted-by":"publisher","first-page":"581","DOI":"10.3389\/fneur.2020.00581","volume":"11","author":"X Wu","year":"2020","unstructured":"Wu X, Liu Y, Nie C, Kang Z, Wang Q, Sun D, et al. Efficacy and safety of intravenous thrombolysis on acute branch atheromatous disease: a retrospective case-control study. Front Neurol. 2020;11:581. https:\/\/doi.org\/10.3389\/fneur.2020.00581.","journal-title":"Front Neurol"},{"key":"1443_CR11","doi-asserted-by":"publisher","first-page":"98","DOI":"10.3760\/cma.j.cn114798-20240806-00667","volume":"24","author":"C Junjie","year":"2025","unstructured":"Junjie C, Lijuan H, Yue L, Yang G. One case of internal capsule warning syndrome. Chin J Gen Pract. 2025;24:98\u2013101. https:\/\/doi.org\/10.3760\/cma.j.cn114798-20240806-00667.","journal-title":"Chin J Gen Pract"},{"key":"1443_CR12","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.81301","volume":"17","author":"T Matsubayashi","year":"2025","unstructured":"Matsubayashi T, Fujiki S, Muramatsu R, Furuki M, Obayashi M. Efficacy of intravenous thrombolysis for the prognosis of branch atheromatous disease. Cureus. 2025;17:e81301. https:\/\/doi.org\/10.7759\/cureus.81301.","journal-title":"Cureus"},{"key":"1443_CR13","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.123.031692","volume":"13","author":"L Wang","year":"2024","unstructured":"Wang L, Hao M, Wu N, Wu S, Fisher M, Xiong Y. Comprehensive review of tenecteplase for thrombolysis in acute ischemic stroke. J Am Heart Assoc. 2024;13:e031692. https:\/\/doi.org\/10.1161\/JAHA.123.031692.","journal-title":"J Am Heart Assoc"},{"key":"1443_CR14","doi-asserted-by":"publisher","first-page":"664","DOI":"10.1007\/s13311-023-01391-3","volume":"20","author":"SE Miller","year":"2023","unstructured":"Miller SE, Warach SJ. Evolving thrombolytics: from alteplase to tenecteplase. Neurotherapeutics. 2023;20:664\u201378. https:\/\/doi.org\/10.1007\/s13311-023-01391-3.","journal-title":"Neurotherapeutics"},{"key":"1443_CR15","doi-asserted-by":"publisher","first-page":"645","DOI":"10.1016\/S0140-6736(22)02600-9","volume":"401","author":"Y Wang","year":"2023","unstructured":"Wang Y, Li S, Pan Y, Li H, Parsons MW, Campbell BCV, et al. Tenecteplase versus alteplase in acute ischaemic cerebrovascular events (TRACE-2): a phase 3, multicentre, open-label, randomised controlled, non-inferiority trial. Lancet. 2023;401:645\u201354. https:\/\/doi.org\/10.1016\/S0140-6736(22)02600-9.","journal-title":"Lancet"},{"key":"1443_CR16","doi-asserted-by":"publisher","first-page":"775","DOI":"10.1016\/S1474-4422(24)00206-0","volume":"23","author":"MW Parsons","year":"2024","unstructured":"Parsons MW, Yogendrakumar V, Churilov L, Garcia-Esperon C, Campbell BCV, Russell ML, et al. Tenecteplase versus alteplase for thrombolysis in patients selected by use of perfusion imaging within 4\u00b75 h of onset of ischaemic stroke (TASTE): a multicentre, randomised, controlled, phase 3 non-inferiority trial. Lancet Neurol. 2024;23:775\u201386. https:\/\/doi.org\/10.1016\/S1474-4422(24)00206-0.","journal-title":"Lancet Neurol"},{"key":"1443_CR17","doi-asserted-by":"publisher","first-page":"611","DOI":"10.1056\/NEJMoa1804355","volume":"379","author":"G Thomalla","year":"2018","unstructured":"Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379:611\u201322. https:\/\/doi.org\/10.1056\/NEJMoa1804355.","journal-title":"N Engl J Med"},{"key":"1443_CR18","doi-asserted-by":"publisher","first-page":"1795","DOI":"10.1056\/NEJMoa1813046","volume":"380","author":"H Ma","year":"2019","unstructured":"Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380:1795\u2013803. https:\/\/doi.org\/10.1056\/NEJMoa1813046.","journal-title":"N Engl J Med"},{"key":"1443_CR19","doi-asserted-by":"publisher","first-page":"641","DOI":"10.1001\/jamaneurol.2019.0351","volume":"76","author":"E Barow","year":"2019","unstructured":"Barow E, Boutitie F, Cheng B, Cho TH, Ebinger M, Endres M, et al. Functional outcome of intravenous thrombolysis in patients with lacunar infarcts in the WAKE-UP trial. JAMA Neurol. 2019;76:641\u20139. https:\/\/doi.org\/10.1001\/jamaneurol.2019.0351.","journal-title":"JAMA Neurol"},{"key":"1443_CR20","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2025.0548","volume":"8","author":"JF Rousseau","year":"2025","unstructured":"Rousseau JF, Weber JM, Alhanti B, Saver JL, Mess\u00e9 SR, Schwamm LH, et al. Short-term safety and effectiveness for Tenecteplase and alteplase in acute ischemic stroke. JAMA Netw Open. 2025;8:e250548. https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.0548.","journal-title":"JAMA Netw Open"},{"key":"1443_CR21","doi-asserted-by":"publisher","DOI":"10.1186\/s40001-025-02983-9","volume":"30","author":"AM Hagag","year":"2025","unstructured":"Hagag AM, Kormod ME, Ads ME, El-Refaay MA, Abozaid OM, Ghanem OA, et al. Tenecteplase versus alteplase in patients with acute ischemic stroke: an updated systematic review and meta-analysis. Eur J Med Res. 2025;30:726. https:\/\/doi.org\/10.1186\/s40001-025-02983-9.","journal-title":"Eur J Med Res"},{"key":"1443_CR22","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1161\/STROKEAHA.125.053256","volume":"57","author":"Z Wang","year":"2025","unstructured":"Wang Z, Li J, Wang X, Yuan B, Li J, Ma Q. Tenecteplase for acute ischemic stroke at 4.5 to 24 hours: a meta-analysis of randomized controlled trials. Stroke. 2025;57:50\u201362. https:\/\/doi.org\/10.1161\/STROKEAHA.125.053256.","journal-title":"Stroke"},{"key":"1443_CR23","doi-asserted-by":"publisher","DOI":"10.1002\/brb3.70756","volume":"15","author":"MH Waseem","year":"2025","unstructured":"Waseem MH, Abideen ZU, Khan MH, Tahir MF, Khan M, Raja HAA, et al. Comparative efficacy and safety of different Tenecteplase doses with alteplase in acute ischemic stroke: a systematic review with pairwise and network meta-analysis to determine the optimal dose. Brain Behav. 2025;15:e70756. https:\/\/doi.org\/10.1002\/brb3.70756.","journal-title":"Brain Behav"},{"key":"1443_CR24","doi-asserted-by":"publisher","DOI":"10.3389\/fneur.2023.1098141","volume":"14","author":"Y Liu","year":"2023","unstructured":"Liu Y, Wang H, Xu R, He L, Wu K, Xu Y, et al. Serum uric acid to serum creatinine ratio predicts neurological deterioration in branch atheromatous disease. Front Neurol. 2023;14:1098141. https:\/\/doi.org\/10.3389\/fneur.2023.1098141.","journal-title":"Front Neurol"},{"key":"1443_CR25","doi-asserted-by":"publisher","first-page":"1416","DOI":"10.5551\/jat.65653","volume":"32","author":"T Hoshino","year":"2025","unstructured":"Hoshino T, Mizuno T, Arai S, Hosoya M, Ishizuka K, Higuchi E, et al. Hemostatic activation markers and early neurological deterioration in branch atheromatous disease-related stroke. J Atheroscler Thromb. 2025;32:1416\u201324. https:\/\/doi.org\/10.5551\/jat.65653.","journal-title":"J Atheroscler Thromb"},{"key":"1443_CR26","doi-asserted-by":"publisher","first-page":"460","DOI":"10.1017\/S1092852919001354","volume":"25","author":"M Elfil","year":"2020","unstructured":"Elfil M, Eldokmak M, Baratloo A, Ahmed N, Amin HP, Koo BB. Pathophysiologic mechanisms, neuroimaging and treatment in wake-up stroke. CNS Spectr. 2020;25:460\u20137. https:\/\/doi.org\/10.1017\/S1092852919001354.","journal-title":"CNS Spectr"},{"key":"1443_CR27","doi-asserted-by":"publisher","DOI":"10.1016\/j.jstrokecerebrovasdis.2019.104564","volume":"29","author":"PR Barreto","year":"2020","unstructured":"Barreto PR, Diniz DLO, Lopes JP, Barroso MC, Daniele TMDC, de Bruin PFC, et al. Obstructive sleep apnea and wake-up stroke \u2013 a 12 months prospective longitudinal study. J Stroke Cerebrovasc Dis. 2020;29:104564. https:\/\/doi.org\/10.1016\/j.jstrokecerebrovasdis.2019.104564.","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"1443_CR28","doi-asserted-by":"publisher","first-page":"475","DOI":"10.1111\/ane.13296","volume":"142","author":"HK Ahmed","year":"2020","unstructured":"Ahmed HK, Logallo N, Thomassen L, Novotny V, Mathisen SM, Kurz MW. Clinical outcomes and safety profile of Tenecteplase in wake-up stroke. Acta Neurol Scand. 2020;142:475\u20139. https:\/\/doi.org\/10.1111\/ane.13296.","journal-title":"Acta Neurol Scand"},{"key":"1443_CR29","doi-asserted-by":"publisher","first-page":"1437","DOI":"10.1001\/jama.2024.14721","volume":"332","author":"X Meng","year":"2024","unstructured":"Meng X, Li S, Dai H, Lu G, Wang W, Che F, et al. Tenecteplase vs alteplase for patients with acute ischemic stroke: the original randomized clinical trial. JAMA. 2024;332:1437\u201345. https:\/\/doi.org\/10.1001\/jama.2024.14721.","journal-title":"JAMA"}],"container-title":["Translational Stroke Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12975-026-01443-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s12975-026-01443-8","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s12975-026-01443-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T08:31:02Z","timestamp":1782376262000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s12975-026-01443-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,1]]},"references-count":29,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,6]]}},"alternative-id":["1443"],"URL":"https:\/\/doi.org\/10.1007\/s12975-026-01443-8","relation":{},"ISSN":["1868-4483","1868-601X"],"issn-type":[{"value":"1868-4483","type":"print"},{"value":"1868-601X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,1]]},"assertion":[{"value":"21 February 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 April 2026","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"25 April 2026","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"1 May 2026","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This multicenter retrospective case\u2013control study was approved by the Ethics Committee of the Fifth Clinical Medical College of Henan University of Chinese Medicine, which is affiliated with Zhengzhou People\u2019s Hospital (approval number 2017L01098). All procedures were performed in compliance with the guidelines outlined in the Declaration of Helsinki.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval"}},{"value":"Given the retrospective design of the study, the requirement for written informed consent was waived.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Participate"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Publish"}},{"value":"The authors declare no competing interests.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"51"}}