The angiographic ICA staging system modified by Mugikura et al.
\r\n\tThis book chapter’s main theme will be focused on transmission dynamics, pathogenesis, mechanisms of host interaction and response, epigenetics and markers, molecular diagnosis, RNA interacting proteins, RNA binding proteins, advanced development of tools for diagnosis, possible development of concepts for vaccines and anti drugs for RNA viruses, immunological mechanisms, treatment, prevention and control.
\r\n\t
The importance of hydrogen sensor both domestically and industrially does not need a fresh introduction. Hydrogen has the prime potential applications as fuel in domestic, nuclear installations, and space vehicles. The huge calorific value and non-polluting by-products of hydrogen combustion are two principal advantages of using hydrogen as a fuel. But the negative aspect is its extremely high inflammability at fairly low concentration (~4% and above) when mixed with air leading to disastrous explosions. So, the use of hydrogen gas for combustion or for any other purpose invariably requires a monitoring and controlling device to detect the hydrogen leakage and to alleviate the serious explosion danger. There are continuous R & D efforts to develop hydrogen sensors in different dimensions and for use at different temperatures.
\nOf late, graphene has been shown to be the most suitable material for hydrogen sensor because of its superior mechanical, electrical, and chemical properties. The two dimensional (2D) structure of graphene is most desirable for the development of miniaturized and fast hydrogen sensor devices. Graphene is a good device material owing to its intrinsic properties. The favorable thermal conductivity (~5000 W/mK) and very high electrical mobility (~200,000 cm2/Vs) are very special attributes for developing excellent electronic devices [1]. Because of very large surface-to-volume ratio graphene is an interesting gas/vapor sensing material that can allow fast and high gas adsorption. The high hydrogen intake ability of graphene and other carbon nanostructures has been reported in the literature [2–4]. It is also reported with experimental evidences that the high hydrogen intake ability of graphene is mainly due to the intercalation phenomenon [5–7]. The basic concept of hydrogen intercalation in graphene is the attachment of hydrogen with the graphene layer at the graphene–substrate interface. For multilayer structures, the intercalation phenomenon also happens between the graphene layers, and hence, large amount of hydrogen interaction is possible [8–10].
\nThe intercalation occurs between graphene and atomic hydrogen. So, the important concern for hydrogen sensor devices based on graphene is the generation of atomic hydrogen. This is due to the important fact that the percolation of molecular hydrogen through graphene is impossible because of the dimensions of hydrogen molecule and graphene network. The C–C lattice parameter is 2.46 Å, and the size (diameter) of hydrogen molecule is 2.89 Å [7]. Hence, hydrogen molecule cannot possibly percolate through the graphene layer. On the other hand, the Bohr radius of hydrogen atom is only 0.5 Å, which will easily allow the hydrogen atom to pass through the graphene layer, and subsequently getting attached with the graphene layer between the substrate and graphene. This attachment will temporarily isolate the graphene layer from the substrate, resulting in the intercalation phenomenon. The attachment of hydrogen atoms with the carbon atoms is via van der Waals forces, and hence, the hydrogen atoms can easily desorb upon the reduction of hydrogen partial pressure at a particular temperature during the recovery of the sensor signal. The generation of atomic hydrogen in graphene-based sensor devices depends on the activity of the graphene surface. For instance, the presence of functional groups can initiate reaction with hydrogen, or the presence of catalytic metal can trap hydrogen and break the molecules into atomic hydrogen. Sometimes, junctions with another semiconductor can also bring interesting sensing attributes.
\nIn this chapter, we shall highlight the graphene-based devices that have potential for developing hydrogen sensors, with appreciably fast response and recovery characteristics at different temperature regimes. Since graphene is a high-temperature material, it can be used for sensing hydrogen and other gases at room temperature as well as at elevated temperature with high efficiency. Again, graphene is a 2D material and so it is convenient to fabricate miniaturized sensor devices for commercial applications. Another unique property of graphene is the reversible inversion of electrical conductivity from p-type to n-type and vice versa with temperature in both oxidizing and reducing atmospheres. The sensing nature can be inverted with equal efficiency with the variation of temperature and environment. This versatile characteristic is rarely found in other sensing materials leading to the innovation of the new kind of junction devices. Graphene can enable smaller and lighter sensors with endless design possibilities. They are more sensitive, can detect smaller changes in matter, work faster, and eventually less expensive than the traditional sensors. Some graphene-based sensor designs contain a field effect transistor (FET) with a graphene channel. Upon detection of the targeted analyte the current through the transistor changes and sends a signal that can be analyzed to determine several variables.
\nThe potential applications of different forms of graphene (including pristine, B- or N-doped and defective graphene) as gas sensors to detect small gas molecules (CO, NO, NO2, NH3, and H2) have been investigated and confirmed theoretically by using density functional computations. The structural and electronic properties of the graphene–gas molecule adsorption adducts principally depend on the structure of graphene and the molecular gas adsorption configuration. The doped or defective graphene exhibits much stronger attraction than the pristine graphene for the above five gas molecules. While the defective graphene shows the highest adsorption energy for H2, CO, NO, and NO2 molecules, the B-doped graphene shows the tightest binding with NH3. Also, the strong interactions between the adsorbed gas molecules and modified graphene can bring dramatic changes in the electronic properties of graphene. Both theoretical and practical evidences support that the sensitivity of a gas sensor using B-doped graphene is almost two orders of magnitude higher compared to pristine graphene. So, the performance of the graphene-based chemical gas sensors can be largely improved using the appropriately doped or defective graphene [11].
\nGraphene can be synthesized by employing different methods. Exfoliation is an easy method, in which graphene layer is isolated from
Single-crystalline silicon carbide wafers can be heated at elevated temperatures to generate the graphene layer [13]. In this case, the silicon atoms escape the wafer leaving the hexagonal carbon network. But the transfer of thermally generated films is a major problem by this method [14].
\nChemical vapor deposition (CVD) is a convenient technique to grow graphene films for sensor applications. For CVD growth, the substrates are coated with a metal (say copper), which acts as the catalytic layer [15]. Apart from copper, other metals such as nickel, silver, gold, platinum, and cobalt can be used for graphene growth [16]. Due to the high solubility of carbon in copper, it is often preferred for graphene growth by CVD.
\nFor CVD growth of graphene films, normally thermally oxidized silicon substrate is the obvious choice [17]. Plasma-Enhanced Chemical Vapor Deposition (PECVD) grown SiO2/Si substrates can also be used. However, the surface quality of thermally oxidized silicon substrates is relatively better in comparison with PECVD substrates. A thin film of copper is deposited on the substrate by e-beam or thermal evaporation technique. The copper layer mainly acts as the catalytic layer which initiates the growth. The precursor is normally a mixture of a carbon containing gas (like CH4), a reducing gas (like H2), and an inert/neutral gas (like Ar/N2) [18]. The important parameters of growth are deposition time, flow ratio of the gases, and the temperature of the substrate. All these parameters need to be optimized to have good device quality graphene films. It is reported that the CH4 molecules decompose on the catalytic copper surface in the temperature range 900–1000°C [19]. This temperature range can be modulated by suitable choice of the catalytic metal. The flow ratio is regulated very precisely with the help of mass flow controllers, owing to the important fact that if too much carbon containing gases are allowed to flow over the heated substrates, secondary nucleation can initiate haphazard growth, leading to poor film quality, which is not desirable for good device performance. Sometimes, oxygen groups need to be attached to the hexagonal carbon network for some specific applications. In that case, very small amount of oxygen can be incorporated into the flow stream during growth. The number of deposited graphene layers depends on the time of deposition and the activity of the catalytic layer. The thickness of the catalytic layer is another important parameter of growth. This is due to the fact that at elevated temperatures during growth, the fresh copper atoms from underneath diffuses through the bulk copper layer up to the surface for fresh reactions. Hence, optimization of the catalyst layer thickness is also an important priority for graphene growth. Owing to the fact that pristine graphene is insensitive to hydrogen and other gases functionalization of the grown graphene layer is often necessary for sensor application. Hence, oxygen functionalized graphene, for example, graphene oxide (GO) and reduced graphene oxide (rGO) are equally important for developing sensor devices. Functionalization with other groups can impart special device properties. Such functionalized layers are especially useful to develop resistive gas sensors. Apart from oxygen and other organic groups, the catalytic metals (Pd, Pt, etc.) are also useful for metal-decorated graphene gas sensors. The catalytic metal nanoparticles (NPs) can simply be dispersed on graphene surface to improve its gas sensing property. By this process, the response parameters such as sensitivity, selectivity, and time of response/recovery can be modulated. Another technique to improve the gas sensing activity of graphene is to disperse graphene layers (obtained by either exfoliation or CVD) in a polymer base [20, 21]. Such mixed composition can give special material properties suitable for gas sensing and other applications.
\nThe characteristics of the graphene-based sensor device depend on both electronic and catalytic properties of the active layer (s). For instance, if the layer is electronically active but insensitive to detecting gases (like pristine graphene), it is not suitable as sensor material. In that case, the sensitivity is to be developed by functionalization or surface modification. Sometimes, both electronic and sensing properties can be achieved by simple surface modification techniques. In fact, the generated charge carriers during sensing need to flow through the device circuit in order to show appreciable sensor response. But just after generation, if the carriers are annihilated or trapped by defects the response, even though happening, will not be observed. Surface modification technique takes care of the defect treatment and restores good electronic attributes, in many cases. Such surface modified layers can be used to develop good resistive sensors, where the important factor is how effective is the surface in capturing the analyte gas molecules, and how efficient the material is in transferring the generated charge to the electrode. The time of response gets prolonged if the solid–gas interaction is slow. However, the recovery of the sensor solely depends on how good is the material electronically. Whether the charge carrier annihilation is minimum or negligible the recovery characteristics are likely to be good.
\nApart from the catalytic properties of the sensing material the I–V characteristics and junction bias are important for the junction devices. Generally, the forward barrier is low compared to the reverse one. However, for the defective active sensing layers, the reverse characteristic of the junction is far from the nature of the ideal diode. Therefore, the sensor performance may differ for the junction devices with forward and reverse biased cases, and hence needs optimization. The junction ideality factor is also an important parameter for hydrogen sensor applications, and it is necessary to improve the ideality factor to obtain the good device characteristics and superior gas sensor characteristics, respectively.
\nThe operational characteristic of a junction device with respect to the junction barrier needs a close attention. The charge carriers generated due to solid–gas interaction reach the junction interface and modulate the junction capacitance. The magnitude of this capacitance is affected by the variation of the junction bias, which regulates the device barrier both in the forward and in the reverse bias operations. Hence, both forward and reverse bias studies are necessary for finding the optimum device characteristics.
\nOptical devices can operate at room temperature or below, which is good for hydrogen safety. Reflectance, transmittance, absorption, refractive index, etc. are the parameters that can be monitored in an optical sensor device. Palladium-based optical hydrogen sensors adsorb hydrogen and forms non-stoichiometric PdHx, which changes the optical properties, mentioned above. Upon hydrogen desorption, the original properties of Pd are restored.
\nSurface acoustic wave (SAW) devices are also popular for gas sensors and are used for hydrogen detection. A transformation of acoustic signal to electrical and vice versa is done in SAW devices with the help of the piezoelectric materials. So, any change in the properties of these piezoelectric materials will modulate the acoustic signal that travels from the input to the output end. An important parameter that is considered for quantification is mass. So, if a gas sensitive material is coated on a piezoelectric substrate, the mass of this material changes upon gas adsorption and affects the traversing of the acoustic signal from the input to the output end. Hence, the synchronous frequency of the signal, which is inserted at the input end, is liable to change upon gas adsorption.
\nIn all the above devices, the material platform is most important, and the device properties are majorly determined by the properties of the sensing material. For sensor devices, the contamination from moisture and other pollutants can alter the device characteristics with prolonged usage. Such deterioration can be prevented by proper device packaging and temperature treatment of the sensing platform in a cyclic manner (low to high and vice versa) to eliminate volatile contaminants.
\nThe traditional semiconductor devices which are used to fabricate the electronic gadgets can be effectively utilized to design and develop the graphene chemical sensors. Different physical and chemical characteristics of the sensing materials and/or the junctions are modified in presence of trace amounts of gases or chemicals. The sensor response is registered as the change of electrical, optical, and chemical properties. The following graphene-based devices are generally used for sensing hydrogen and other trace amount of chemicals, gases, and vapors.
\nThe surface sensitivity of materials is normally harnessed by fabricating a simple resistive-type sensor with interdigitated electrodes or with two parallel electrodes (Figure 1). Interdigitated electrodes are preferred when the material conductivity is not uniform throughout the exposed surface.
\nResistive devices with different electrode configurations.
In case of graphene, pure pristine graphene surface may not be very lucrative to develop simple resistive sensors. However, other forms such as reduced rGO, or surface functionalized graphene, or catalytic NP dispersed on graphene, etc. are useful to develop resistive sensor devices. Zhou et al. [22] reported room temperature operation of resistive sensor devices based on rGO. The flow rates of the test gases influence the adsorption of gases on the active surface, and hence the sensitivity of the resistive device. Also, the rGO thickness is an important parameter for obtaining optimum response characteristics.
\nPure platinum (Pt) and bimetallic platinum–iron (Pt3Fe) NP were used to decorate nitrogen-doped graphene to develop resistive hydrogen sensors [23]. Polyol technique was used to synthesize the NPs and subsequent decoration. The sensors were responsive to 4 vol% hydrogen and could be used for room temperature sensing. Pure Pt decoration yielded 47% response, while bimetallic Pt3Fe yielded 35% response in 4% H2 gas ambient. Pt NP decoration on rGO was also done to develop hydrogen sensors by Ghosh et al. [24]. The response of the devices in H2/air ambient varied from 19% (200 ppm) to 57% (5000 ppm), and the response time of the devices in air was ~65 s [24]. Similar hydrogen sensor studies with bimetallic-graphene composites are reported [25]. The electrical resistance was measured in 2% H2/Ar ambient in the temperature range −100 to 100°C. The reported response at room temperature is 4.3%. Optimum response was obtained at 40°C with the response time of 2 s.
\nGraphene flakes of nanoscale dimension- and spherical-shaped nanoporous palladium particles were combined to make the sensitive platform to fabricate resistive sensors [26]. The sensors were sensitive to hydrogen (10,000–1 ppm) at room temperature. The resistive devices showed repeatable response, recovery and a very high hydrogen selectivity during operation near room temperature. The appreciably good selective response to hydrogen is due to the high affinity of palladium to hydrogen relative to other gases. Also, the relatively lower activation energy for hydrogen adsorption is due to the porous nature of nanosize palladium. As a result, the resistive devices can operate even at room temperature.
\nGraphene nanoribbons (GNRs) have recently shown the novel physical, electronic, and spin transport properties for the wide range of device applications. Graphene nanoribbon in combination with Pd NPs can also be used for hydrogen sensing [27]. The graphene nanoribbon was fabricated by laser-assisted lithography. The nanoribbon of 200 nm width was patterned at a separation of 1 μm. In an atmosphere of 1000 ppm hydrogen in nitrogen, 90% response was obtained with a response time of 60 s. Almost 80% recovery could be achieved in a time span of 90 s. The devices were also sensitive to other gases. The incorporation of NPs in GNR-based gas sensors can be a novel approach to develop the high-performance gas sensors.
\nAn interesting work on Pd–graphene resistive hydrogen sensor operating with and without bending strain was reported by Yi et al. [28]. A graphene mesh was developed by CVD technique using flexible PET as the substrate. The variation of the resistance of the simple Pd–graphene and the Pd–graphene mesh with bending/unbending cycle was investigated. It was revealed that the simple Pd–graphene showed relatively higher resistance change during bending in air compared to Pd–graphene mesh. The Pd–graphene mesh sensors are more stable to stress for the real field installations with a curvature. At room temperature, the hydrogen response of the Pd–graphene mesh sensor was 1.25 times higher than the simple Pd–graphene in the concentration range 2–15 ppm. Probably, the edges of the graphene mesh provided an additional surface for enhanced hydrogen adsorption and response for hydrogen. The use of flexible substrates was also reported by Chung et al. [29].
\nThe important concern for sensor devices is to attain good response parameters. This can be achieved by reducing the geometrical device area significantly. The geometrical contact area of the catalytic dot contact devices can be made very small. Both planar and vertical configurations (Figure 2) are used in this case. The vertical devices are sometimes advantageous because the total vertical transport path of the generated charge carriers is short, which ensures minimum carrier loss due to annihilation and trapping. For transferable graphene films (like those obtained by exfoliation), both planar and vertical devices can be conveniently fabricated. However, for graphene films obtained by CVD on SiO2/Si substrates (with undoped silicon), the planar device fabrication is more suitable because the insulating SiO2 is the hindrance for vertical device fabrication. However, if the silicon wafer is highly doped and the barrier SiO2 layer is very thin, the vertical configurations can be possible to fabricate a catalytic dot contact device for hydrogen sensing.
\nPlanar and vertical device configurations.
The reduction in the geometrical area makes the sensor device saturate quickly during response and recover fast due to less adsorption. Hence, the response parameters such as time of response and time of recovery are faster, the essential criteria of an efficient gas sensor. However, the magnitude of % response is relatively less but it is not a big issue in today’s sensor research due to advanced electronic circuitry that can amplify signal electronically to get higher electrical output. If the sensing platform is defective in nature, the number of active sites for gas adsorption is higher compared to the defect free matrices. The graphene film grown by CVD is usually defective but it is suitable for gas sensor applications [18, 19]. As reported by Dutta et al. [19], multilayer graphene films on SiO2/Si substrates showed good response characteristics for hydrogen, with fast response (~12 s). The defective nature of the films was estimated from Raman studies. The nonuniformity of the films was corroborated by Field Emission Scanning Electron Microscope (FESEM) and Atomic-Force Microscopy (AFM) studies. So, considering the defective nature and the uneven surface topography of the CVD grown films, it can be inferred that any catalytic contact on the surface of CVD grown graphene should have large number of active sites for gas adsorption leading to high gas sensitivity. Dutta et al. [19] fabricated Pd/graphene/Pd planar devices using the graphene samples, grown by CVD for 15 min at 1000°C, and obtained good hydrogen sensitivity in the temperature range 110–150°C. The planar device was found to be insensitive to another reducing gas, methane, possibly due to insufficient thermal activation energy to dissociate the large methane molecule. The interesting observation reported by Dutta et al. [19] was the change in the surface morphology after hydrogen exposure. The reorientation of the graphene surface after exposure to hydrogen gas was probably due to the hydrogen passivation of the surface defects. In another study by the same research group using planar Pd/graphene/Pd junctions with graphene grown by CVD for 8 min at 1000°C, hydrogen was detected from room temperature to 150°C [30]. The junctions showed a change in the conductivity from n- to p-type at around 100°C and above, eventually due to hydrogen intercalation that has already been discussed in the introduction part. If current increases upon exposure to hydrogen, it is referred to as n-type sensitivity due to n-type conductivity of the device matrix. And it is p-type response if the current decreases in the presence of hydrogen. At 150°C, the p-type response was reported to be very fast (1–2 s) for the same junction devices, which were very stable in the temperature range 25–150°C. The above discussion supports in favor of using defective graphene thin films as the catalytic contact devices for efficient hydrogen sensing.
\nReports are available on the vertical devices with Pt contacts on the surface of graphene grown on SiC substrates [31]. Typical multilayer vertical device geometry is shown in Figure 3. Normally, the bottom metal contacts ensure good ohmic metallization, while the top metallic contact is catalytic in nature to accelerate the sensor performance. As reported by Shafiei et al., titanium and platinum multilayer bottom contacts, that is, metal-1 and metal-2 shown in Figure 3 were used in this study. The graphene films of thickness ~10 nm or less were obtained by the reduction of spray-coated graphitic oxide film. The catalytic metal (Pt) dot (metal-3 in Figure 3) accelerated the dissociation of hydrogen molecules during sensing. The devices were operated at 100°C, in an ambient of 1% hydrogen mixed with air. The response was recorded in terms of voltage shift in the dynamic response patterns. At 100°C and in 1% H2 in air, a 100 mV voltage shift was reported under a current bias of 1 mA.
\nA simple multilayer vertical geometry for graphene-based sensor.
An important condition for both planar and vertical dot contact devices is that the contacts must be ohmic with low contact resistance. Different metal contacts to graphene layers have been studied and reported [32]. The metals selected and reported in this study are Al, Ti, Ni, Cu, Pt, and Pd. The bilayer of either of these metals (10 nm) and gold (50 nm) was deposited on graphene, and the contact resistance was measured. The contact resistance was almost similar in all the cases, and it was improved by different pretreatment. For instance, oxygen plasma treatment of the graphene surface prior to metal deposition gave lower contact resistance when compared with the untreated surfaces or post-processed contacts. The masking is necessary to ensure selected area plasma treatment; otherwise, the graphene surface properties are likely to change. However, Robinson et al. [32] did not report any surface degradation. Post-plasma treatments like thermal annealing at the temperature >450°C, showed a further decrease in contact resistance. A very low value of contact resistance (4.5 × 10−8 Ω cm2) was obtained when annealed in the temperature range 450–475°C for 15 min. There is a chance of reduction of the surface carrier concentration upon annealing; however, the carrier mobility is preserved or further improved. Due to removal of volatile impurities from the graphene surface during annealing, the doping level is eventually decreased, thereby reducing the surface concentrations and increasing the purity. So the mobility remains intact or is improved to certain extent. Sometimes, ohmic contacts are used in the vertical devices for hydrogen sensing by displaying the change in the contact resistance. Zhang et al. [33] reported on the transfer of graphene nanoribbon (GNR) onto doped Si substrates with a native oxide layer and decorated with Pd NPs for hydrogen sensor applications. Carbon nanotube (CNTs) unzipped by a simple chemical reduction process was the source of graphene. Also, the synthesis of metal NPs and their incorporation in the unzipped CNTs were done during the chemical reduction. In the vertical structure, silver contact was made on top of the graphene surface and indium at the bottom of silicon substrate. The device sensitivity for 100 ppm H2 in air was appreciably high to 94% at room temperature. In fact, this vertical structure showed better hydrogen response than the bare and simple resistive Pd–graphene nanoribbon in the identical condition.
\nA Flow chart for the vertical device fabrication is shown in Figure 4 below.
\nA schematic process flow for the fabrication of Pd-decorated graphene hydrogen sensors.
The improvement in response can be attributed to the concept of enhanced junction sensitivity relative to the simple devices. The vertical junction, (Pd–GNR)/(thin SiO2 barrier)/(doped p-Si), acts as a simple p–n junction device with the Pd–GNR acting as the n-layer. The junction sensitivity in terms of barrier modulation has been discussed in Section 3 of this chapter. The planar Pd–GNR acts as a simple resistive device, whose surface interactions are similar to the vertical device, but the device speed is low and has relatively higher chances of carrier annihilation due to the planar configuration (also discussed in the beginning of this section). A similar vertical catalytic dot contact Schottky device with rGO (Pd–rGO–SiO2–Si) was reported by Du et al. [34] with high sensitivity for hydrogen at room temperature.
\nJunction devices are fabricated with a goal to harness the high-charge carrier mobility of graphene (first layer) in coordination with other attributes of the second layer (either conventional semiconductor like silicon or oxides). Graphene-metal oxide heterostructures are suitable for versatile applications [18, 35–37]. The main advantage of graphene-based heterojunction is the tunable interface barrier, which makes these devices suitable for different applications including chemical sensing as the major area [38]. A basic schematic of a heterojunction device is shown in Figure 5a.
\nSometimes, both the pristine graphene layer and the conventional semiconductor of the heterojunction are insensitive to a test gas. In that case, the catalytic metals are to be used to initiate the gas sensor performance. Surface functionalization of the graphene layer can also be an alternative step to improve the sensitivity of the graphene based heterojunction. Normally, graphene-based heterojunction with other gas sensitive materials (like metal oxides, etc.) is likely to show improved sensor performance due to good electronic transport properties of graphene and excellent surface property of the oxide (in terms of gas adsorption/desorption), and scope of interface barrier modulation. The heterojunction can be fabricated by either transferring the graphene layers onto an oxide substrate or CVD grown graphene can be used as a substrate to deposit the oxide film.
\nA graphene/silicon heterojunction can be biased with pre-optimized bias voltage (either in forward or in reverse bias mode) to perform the sensor studies in a desired gas ambient. Uddin et al. [39] performed hydrogen sensor studies in reverse bias mode with palladium- and platinum-functionalized graphene/silicon heterojunction. The sensitivity of the junction is dependent on the junction bias, which ensures high band bending in the presence of test gas. The graphene/Si heterojunction showed high sensitivity to sub-ppm hydrogen. Liu et al. [40] used CVD grown graphene as substrates to grow ZnO nanowires in order to develop ZnO/graphene nanojunction. These junctions showed hydrogen sensitivity at relatively lower temperatures (<100°C).
\n(a) Schematic of a heterojunction device. (b) Comparative sensor recovery in air and nitrogen ambient [
A typical hydrogen response behavior of the p-TiO2/n-graphene heterojunction at different hydrogen gas concentrations and temperatures has been reported by Dutta et al. [18]. The hydrogen response of the p-TiO2/n-graphene heterojunction in the temperature range 75–150°C, revealed efficient, selective, and stable performance at 100°C. The selective performance was checked by using another reducing gas like methane. Also, an interesting study regarding the device recovery was reported in this work. As shown in Figure 5b, the p-TiO2/n-graphene heterojunction could easily recover back to its baseline value after cutting off H2 in air and the recovery was incomplete when H2 was cut off in N2 ambient. However, the response was similar in both the cases. Hence, it is evident that oxygen plays an important role in the signal recovery process by releasing hydrogen atoms via water formation as shown in Eq. (1) below [18]:\n\n
Sometimes, the heterojunction configuration also helps in improving the recovery characteristics. While pristine rGO (before and after annealing and with/without UV light exposure) as reported by Kang et al. [41] showed relatively poor recovery characteristics to NO2, the nano-heterojunction sensor based on rGO and functionalized with tin dioxide nanocluster showed good recovery upon annealing and exposure to UV light. In fact for an optimized tin dioxide functionalization time of 55 min, the nano-heterojunction showed 100% recovery. The good recovery could be attributed to the modulation of the heterobarrier at the nanocontacts between tin dioxide and graphene under UV illumination, which enhanced the rate of surface reactions.
\nSimilar type of nanoscale composite junctions was fabricated with Pd–WO3 nanostructures and partially rGO by employing a hydrothermal process [42]. This composite material was sensitive to a wide concentration range of hydrogen (20–10,000 ppm) in the temperature range 25–250°C. Simply adding GO to Pd–WO3 nanostructure showed nearly half the response shown by the nano-heterocomposite between Pd–WO3 and partially rGO. This could be attributed to the difference in surface area and unsaturated oxygen functional groups between the two, which modulated the surface adsorption. Pd and Pt NPs are sometimes used to decorate heterostructures. As reported by Esfandiar et al. [43], TiO2/rGO was decorated by Pd and Pt NPs. The reported hydrogen sensitivity of such decorated heterostructures was 92% in 500 ppm hydrogen in air, and the device response time was <20 s at 180°C.
\nAnother type of heterostructures is graphene/Si-nanowire (Si-NW) array for molecular sensing. Such heterostructures are fabricated by using single-layer graphene vertically contacted with high-density Si NWs. Silicon nanowires produced by metal-assisted chemical etching of Si wafer are vertically aligned on CVD grown graphene. Si NWs stand on Si wafer detached from each other under graphene. The uniform Schottky-type junction between Si NWs and graphene thus produced act as the molecular sensors and respond very sensitively to hydrogen gas molecules in air with 1280% resistance change with 0.15 s response/recovery times, the highest performance so far reported. The surface-transfer doping mechanism was suggested based on the results together with the sensor response in vacuum [44].
\nThe response of optical sensors is normally monitored in terms of the parameters such as reflectance, absorbance, refractive index, and photoluminescence [45]. The configuration of a typical optical sensor assembly is shown in Figure 6.
\nOptical fiber sensor assembly.
The increasing concern of safety demands the room temperature operation of non-electrical gas sensor devices. Hence, the use of optical gas sensors is important. Graphene can be used to develop optical gas sensors for the detection of hydrogen and other gases such as CH4, NH3 [46, 47]. For the development of optical gas sensors, graphene has the preference. The chemical stability, affinity to inorganic and organic molecules, scope of surface functionalization and synthesis of composites with catalytic metals and/or other materials make graphene a suitable choice in the field of optical gas sensors [48].
\nThe important step for the development of optical sensors is the transfer of the films from opaque substrates or from substrates with different optical properties. The exfoliated graphene films can be transferred onto any substrate as per the requirement, but for the CVD grown graphene films, the transfer process is complex. Moreover, the substrates must be able to withstand high temperatures because CVD is generally a high-temperature deposition process. Only low-temperature CVD (using good catalytic metals to initiate graphene deposition) is preferred. Lee and coworkers [49] reported on the deposition of graphene films on glass substrates at 450°C using nickel catalytic layer. Although Lee et al. used such low-temperature grown CVD films for humidity sensing, it can also be suitable for hydrogen and other gas sensing. The possibility of surface functionalization can improve the sensing performance. Furthermore, CVD grown films adhere well to the substrates in addition to its stable nature. Quartz substrates can be used instead of glass, if the optical transmission properties of the substrates are to be modulated for gas sensing. So, graphene can also be an appropriate material for the development of optical gas sensor devices.
\nThe basic ideas regarding the operation of SAW devices have been discussed in the earlier section of this chapter. SAW is a well-known sensor device, and many sensor studies have been reported. The main concern here is the growth or transfer of graphene films on a piezoelectric substrate. The rest of device fabrication steps, like patterning of electrodes, are simple. SAW resonating platforms based on LiTaO3 have been used for different gas sensing purposes [50]. A typical SAW platform is shown in Figure 7 below:
\nSurface acoustic wave (SAW) device.
The use of graphene-based LiTaO3 SAW device has been reported for hydrogen sensing [51]. The graphene nanosheets were deposited on the LiTaO3 substrate and exposed to hydrogen (0.06–1.0%) in air at room temperature. A typical frequency vs time response pattern was obtained upon hydrogen exposure, from which the response and recovery times were calculated. While the response time decreased with increase in gas concentration, the recovery time increased with increase in gas concentration. Probably, room temperature is not sufficiently enough to ensure complete desorption from the high adsorbing graphene surfaces and therefore, the recovery time is prolonged. Similar devices like graphene-based Rayleigh SAW Resonators fabricated on quartz were used for sensing oxidizing gas like NO2. The response was good, and the high sensitivity to NO2 gas was attributed to the defects in the material responsible for the increased gas adsorption [52]. There are also other reports on the use of graphene-based SAW devices for sensing gases like dimethyl-methylphosphonate (DMMP) and dipropylene glycol monomethyl ether (DPGME) are available [53].
\nTwo grapheme-based prospective devices for hydrogen sensing.
\nSince 2D graphene can be doped n- or p-type like other semiconductors the graphene p/n homojunction can in principle be designed and fabricated using the traditional semiconductor processing technology. Although quite a few reports on the doping of graphene are available in the literature [54, 55], reports on the use of graphene p/n homojunction as hydrogen sensor is not yet available. The main technical problem during the formation of such junction is eventually the extremely thin dimension of the graphene geometry. Therefore, the technology must be very advanced and sophisticated to realize a successful and sustainable graphene p–n junction. Once succeeded, the graphene p–n homojunction can develop the most efficient hydrogen sensors with miniaturized dimension.
\nThe investigation on the gas-sensing properties of a metal-decorated device comprising two-dimensional (2D) flakes of molybdenum disulfide (MoS2) and graphene electrodes has been reported. This hybrid structure was used to sense ~1 ppm NO2 gas and ~10 ppm NH3. Such metal-decorated sensors operate with the mechanism of chemical as well as electronic sensitization. The metal NPs could harness the electronic properties of the 2D graphene/MoS2 device and enhance the sensitivity for a specific gas molecule.
\nThis work cited an example of NH3 sensing by graphene/MoS2 using palladium NPs via accumulation of hole carriers and NO2 detection using aluminum NPs through depletion of hole carriers. The synergistic combination of metal NPs and the 2D hybrid layers of both graphene and MoS2 could be utilized for application of this sensor structure as a flexible gas sensor. It was also demonstrated that this hybrid sensor structure did not show any sign of degradation in sensing before/after 5000 times bending cycles. So, this highly sensitive and endurable gas sensor could be used as the wearable electronic sensing device. It was also demonstrated that the metal-decorated 2D graphene/MoS2 hybrid structure could be effectively used as a selective gas sensor. So, the hybridization of metal NPs and 2D materials could develop a highly sensitive, selective, reliable, and flexible gas sensor by appropriate selection of the metal NP for decoration [56]. The same device configuration could be strategically employed to develop a selective hydrogen sensor.
\nAn important issue with gas sensor devices is the signal drift with time, and it is a matter of concern for the reliable operation of the sensors. The baseline parameter (either resistance or current) can vary with time, and this is not good for device compatibility with the control electronic circuit. There is also high chance of generating a false alarm. Such drifting can solely be attributed to the material interaction with the atmosphere. Normally, sensing surfaces are very active, and hence can have constant adsorptive/desorptive interaction with the operating atmosphere, which is normally oxidative air ambient (with some humidity concentration). And if the sensing material is defective, which is sometimes an added advantage for gas sensors, such interactions are pronounced. This can lead to change in the baseline resistance with time. Of course, a saturation of the drift is likely with time. However, the process is very slow, and hence, the change is sometimes unpredictable. Moreover, the ambient temperature, if it varies, can change the adsorption/desorption eventually. As a result, the device needs proper calibration both to counter the drift and to have operation in the linear regime of the device characteristics. The calibration is reported for hydrogen sensors [57]. In reality for any device, the linear operational regime is found by plotting the measured parameter (either resistance or current or voltage) with gas concentration. If the plot is throughout linear, the device will have excellent operation at all gas concentrations. However, if the plot is nonlinear, the device needs to be operated in the concentration range where it has linear characteristics.
\nHumidity is an important concern, and the interference of humidity during sensing other gases is very crucial for all the chemical sensor devices including the graphene sensors. The interference of moisture in the operation of graphene-based sensor devices can be realized and explained in the following manner. The water molecules coming in contact with the graphene surface can interact in two different ways at two different regions of the sensor surface. First, the exposed pure graphene surface (devoid of any catalytic material) attracts polar water molecules and makes hydrogen bonds (one or more hydrogen bonds). During sensing such graphene-adsorbed water complexes transfer very little charge to the active region of the surface, that is, the junction. As an example, the magnitude of charge transfer can be realized from the reported data, that for single walled CNTs (with tube-water separation of 2.69 Å), the charge transfer is of the order of 0.035e, where “e” is the electronic charge [58]. So, the device sensitivity might not be influenced much due to this interaction. However, if the charge exchange is of higher magnitude, the device sensitivity may increase and this is possible if the surface is modified with the functional groups. And for most of the resistive sensors, pristine graphene needs to be modified in some way or other.
\nThe second type of interaction with moisture can happen on the portion of the surface where catalytic materials (like palladium, etc.) are present. On the catalytic surface, water can ionize into H+ and OH− and H+ is likely to be preferentially adsorbed due to the high affinity of catalytic materials (like palladium) to hydrogen. Eventually, the adsorbed H+ species can increase the concentration of hydrogen at the interface. On the other hand, if the operating temperature is not very high, the OH− species can occupy/block some of the active sites of the catalytic surface, and the device sensitivity is likely to be affected. Also the sites blocked by OH− species can prevent further adsorption of the incoming H2 molecules followed by its dissociation and release of electrons. As a result, the device sensitivity can be affected. So, the presence of moisture can initiate either or both of the above two mechanisms and influence the response characteristics.
\nAn important aspect is the operating temperature during sensor measurements. If the temperature is high (≥100°C), the moisture molecules will easily desorb, while at low temperatures, the interference is likely to be predominant. Therefore, considering all the factors discussed above, the relevant studies are necessary by varying the relative humidity from low (~30%) to high (~90%) to evaluate the moisture interference at the optimum temperature of sensing, for developing a reliable sensor in the commercial scale.
\nThe reliability and the robustness of the graphene-based gas sensors can be established from the stability studies. The devices are kept under a constant bias for a very long period either in the ambient of a mixture of test gas in air or in simply aerial atmosphere, and the magnitude of the signal (either resistance or current or voltage) is monitored with time. This study can be made continuously for a number of days, and the cumulative data are analyzed. Normally, the stable signal value recorded in the presence of the test gas for a period of one week or so can ensure the stability criteria of an activated sensor. Of course, the background signal without the test gas needs to be checked and calibrated from time to time. The stability study can also be conducted in a discontinuous manner by switching off the sensor device after each day operation and reactivating (by setting in the proper temperature and bias) the next day. Such studies are necessary for the commercial deployment of a reliable sensor device. Dutta and coworkers [18, 19] have reported such studies for graphene-based hydrogen sensors (Figure 8).
\nA typical stability study with graphene-based sensor [
The selectivity is a pertinent sensor parameter and a matter of concern for gas sensor devices. Almost all the renowned laboratories of the world working on the gas sensor devices consider the selectivity problem a major hurdle against the development of a complete gas sensor. Various methodologies are tried to sort out the problem of cross-sensitivity. Like the well-established oxide-based gas sensors graphene-based gas sensors also face cross-sensitivity problem.
\nNormally, the problem of cross-sensitivity is tackled by the following sensor operation factors:
Operating temperature
Gas concentration
Material characteristics and catalytic activity.
The operating temperature is a convenient way to eliminate the cross-sensitivity of other gases. For instance, in the case of sensing hydrogen in a mixture with another reducing gas like methane, the lighter gas like hydrogen can be detected at relatively lower temperature compared with methane, a heavier gas, because the heavier molecules require relatively higher activation energy for dissociation and sensing. Hence, some devices can be selective to hydrogen at relatively lower temperature. In the studies performed by Dutta et al. [18, 19, 30] with Pd/graphene and graphene-based heterojunction (Figure 9) for hydrogen sensing, it was shown that the devices were sensitive to H2 but insensitive to CH4 in the temperature range 75–150°C. This establishes the fact that hydrogen sensing operating temperature does not provide the required activation energy to dissociate heavy molecules like CH4.
\nThe selective response of TiO2/graphene heterojunction sensor toward hydrogen gas [
The concentration of the sensing gas can determine the device selectivity. Basically, the sensitivity (or % response) is proportional to the gas concentration or the partial pressure of the test gas during sensing. If the partial pressure of the gas is high, the response magnitude becomes high. In the presence of two or more gases, it is likely that the gas component with higher concentration will have relatively higher response at the optimum temperature. In other words, if the gas concentration of the interfering gas (es) is lowered the response magnitude becomes negligible. Then, the device will have dominant sensitivity to the particular gas of interest showing the maximum response. The third important factor is the nature of the sensor surface and its catalytic potential. For example, pristine graphene surface may not be effective for sensing all kinds of gases. So, the surface activity can be improved by functionalization using the catalytic metals, such as palladium, platinum, or by physical/chemical treatment. For instance, studies with pure graphene and Pd–graphene nanocomposite were carried out for sensing hydrogen (1%), moisture, and NO2 (38 ppm) in a mixture [59]. The response magnitude to 38 ppm NO2 was excellent with pure graphene but poor with Pd–graphene nanocomposite. On the other hand, the response to 1% H2 was excellent with Pd–graphene and poor with pure graphene. Moreover, the response was relatively faster for Pd–graphene device due to the catalytic influence of Pd. Furthermore, the presence of moisture influenced the response of Pd–graphene more in comparison with pure graphene. The obvious conclusion from the above study is that palladium-containing graphene sensors will be very good for hydrogen detection; pristine graphene (or functionalized with oxygen species) will be very useful for detecting oxidizing gases, like NO2. In case, other reducing gases are to be detected, suitable choice of catalytic metal and operating temperature are necessary. The influence of moisture has to be carefully estimated by separate studies in order to have more assuring results.
\nGraphene has very high potential for chemical gas sensor applications due to its excellent transport properties, superior mechanical properties and immense scope for the modulation of its surface property by functionalization [60]. Since the surface catalytic property influences the solid–gas interaction, surface functionalization is a convenient technique to improve the response characteristics of graphene-based sensors. The use of catalytic metals such as palladium, platinum, nickel can emphasize the manifold response characteristics and the selectivity. The graphene synthesis methods also play a vital role to increase the device compatibility, and the growth of good quality graphene films requires careful studies with the growth parameters in order to be useful for practical hydrogen and other gas sensors. The various types of graphene-based sensor devices and their sensing mechanisms, particularly for hydrogen sensing, have been discussed in this chapter. The discussions are directed toward understanding the potentiality of the graphene-based devices and their huge promise as a gas sensing platform. The gas detection limit of graphene hydrogen sensors may vary from low to high, which is again a device-dependent characteristic. Normally, catalytic surfaces can detect very low concentration of gases at relatively low temperatures. The importance of defects is quite important for chemical gas sensing, and it is evident from the studies reported so far that the defective surface has high capacity for adsorption, the first step of gas sensing. However, recovery of the sensor signal can be perturbed to some extent due to the gas trapping in the defective sites and it needs relatively higher temperature to remove the adsorbed gases. The multilayer graphene (MLG) hydrogen sensors have normally high response and fast response time at room temperature/moderately high temperature, but the recovery is delayed. However, high-temperature sensing registers faster recovery.
\nIssues like drift, calibration, stability, selectivity, and the interference of humidity of the graphene-based sensor devices have been thoroughly discussed. These concerns are elaborately considered with special emphasis on the techniques to avert the problems with a simple solution. Sometimes, very simple and judicious choice of some parameters (like temperature) can solve complicated cases of device selectivity in mixed gas ambient. Till date, cross-sensitivity has been an evergreen and challenging problem of the gas sensors in general and the graphene-based devices for hydrogen sensors in particular.
\nDue to progress in graphene-based research, it is likely that new synthesis techniques may allow the growth of complex device structures, suitable for developing ultra fast sensor devices with selective response characteristics. The problems of suitable ohmic metallization can be addressed if low-temperature CVD techniques are successfully devised. And this will simplify the process steps to fabricate vertical and planar category devices. Also, the quality of the graphene layer can be improved via innovative growth methodologies. These will eventually solve recovery related issues of the graphene-based gas sensor devices. Moreover, it is of utmost importance to understand the operational mechanism of the graphene device at the basic level in order to improvise the ways to improve the performance of the graphene-based sensor devices.
\nMoyamoya disease [MMD] is a form of chronic cerebrovascular occlusion characterized by occlusion of terminal internal carotid artery [ICA] along with a network of collateral vessels at the base of the brain. The disease was first brought to light by Takeuchi and Shimizu, where they described a young man with bilateral occlusion of ICA which was found to be due to congenital hypoplasia rather than atherosclerotic lesion [1]. Similar cases have been described in Japanese literature. After that, the condition came to be known by various names and the term ‘spontaneous occlusion of the circle of Willis’ by Kudo gained popularity [2]. The disease was finally coined ‘
This cerebral angiopathy is broadly termed ‘moyamoya phenomenon’ comprising of two nosological entities. The cerebrovascular syndrome is called ‘Moyamoya syndrome’ [MMS] when it is associated with neurological and extra neurological diseases like Neurofibromatosis 1 [NF1], Down syndrome, thyroid disease, cranial irradiation, sickle cell anemia, among other pathological conditions [4]. The Guidelines of the Research Committee on the Pathology and Treatment of Spontaneous Occlusion of Circle of Willis defined isolated moyamoya angiopathy as being idiopathic and called it ‘Moyamoya disease’ [5].
MMD is more common in Asian ethnicities as compared to the Western population [6]. The increased prevalence in Japan, Korea and other East Asian countries raised genetic predisposition to this condition. Subsequently, Kamada
A literature search was conducted using PubMed. The keywords used were Moyamoya disease, Moyamoya syndrome, ‘puff of smoke’, Suzuki classification, angiography, revascularization procedures etc. Relevant articles were reviewed in detail. The search was filtered to include as many recent publications as possible. An effort was made to compile and highlight the key differences in the disease’s clinical profile from East to West.
For a very long time, Moyamoya disease was thought to be a disease of Asian lineage, but now it has been observed to be prevalent across the world in people with many ethnic backgrounds. MMD has been most extensively studied in Japan, where it is the most common pediatric cerebrovascular disease [8]. It shows a prominent East–West gradient, with a in East Asian countries ten times higher than the Western countries [9]. MMD is most frequently seen in Japan, with an incidence of 0.35–1.13/1,00,000/year and a prevalence of 3.16–10.5/1,00,000 [10]. In a study done in Hokkaido, Japan, 267 new cases were diagnosed between 2002–2006 [8]. The incidence and prevalence were also found to be high in other Asian countries like Korea, China and Taiwan [11]. The incidence in all these countries is found to be increasing over the years, most likely due to advancements in diagnostic modalities and a better understanding of the genetic factors linked to the disease [12]. Studies from outside Asia are very few. The incidence in Washington state and California was 0.086/1,00,000, but in them the incidence in Asian Americans was 4.6 times that of White [9]. In Europe, the incidence of MMD was 1/10th of that in Japan. North America’s incidence was as low as 0.09/1,00,000 individuals, although an increasing trend is now being noted [13].
A similar bimodal age distribution is seen across the world, with the first peak occurring at 5–14 years in the pediatric population and around 4th decade in adulthood [5]. In Japan, family history is present in 10–15% of cases, and the risk of the disease in a family member is about 30–40 times higher than the general population. A familial predisposition was less commonly seen in European countries. In most countries, the disease was more frequently seen in females, with male to female ratio ranging from 1:1.8 to 1:2.2 [10, 14]. These epidemiological parameters remained constant from East to West as evident in the literature review from across the world by Kim et al. [6].
The pathological features have been described based on autopsy findings of cases of MMD. The most common lesion is intracranial hemorrhage, which occurs in basal ganglia, thalamus, hypothalamus and brain stem. The intracranial hemorrhage may show intraventricular extension. Other findings are subarachnoid hemorrhage and small infarcts in the capsule- ganglionic area [14]. The main pathological findings according to the vessels involved are mentioned below.
Thus, the pathology of the disease can be viewed as ICA [Internal carotid artery] to ECA [External carotid artery] prism, where the contribution of ICA to cerebral blood supply gradually decreases, and the compensatory vascular network is formed which is predominantly fed by ECA.
The mechanisms leading to the above-mentioned pathology are not entirely known. It is not clear what leads to migration and proliferation of smooth muscle cells in the intima and leads to its thickening. Moreover, why this thickening happens only in the circle of Willis is unknown. Many features of the disease point towards a hereditary predisposition- high incidence in Japanese people, familial occurrence, association with other congenital disorders like sickle cell anemia, neurofibromatosis, Down syndrome, etc. A multifactorial mode of inheritance has been suggested. A possible linkage of the disease with markers located on chromosome 6, chromosome 17, chromosome 8q23 has been suggested [18, 19, 20]. Recently, a genetic locus in the Ring Finger Protein [RNF] 213 gene was also associated with MMD [7]. A higher carrier rate in Eastern Asia probably explains the higher prevalence of the disorder in Japan and other eastern Asian countries as compared to the Western world [21].
Moyamoya angiopathy has been identified with many genetic disorders like Neurofibromatosis 1, Noonan syndrome, Costello syndrome, Sickle cell disease, GUCY1A3 mutations, BRCC3/MTCP1 gene mutation, Down syndrome, Turner syndrome, etc. [19] Moyamoya disease associated with other familial or acquired conditions has also been termed as ‘quasi-MMD’. It was noted that unilateral presentation was more common than bilateral and hemorrhagic manifestations were less common in quasi- MMD [21].
Although genetic predisposition to the disease exists, the majority of cases are sporadic. Certain acquired factors have been suggested for disease progression. These include vasculitis [3], infections [20], cranial trauma [22], post-irradiation state [23] to name a few.
The pathological changes in cerebral arteries lead to cerebrovascular events in Moyamoya disease. Two peaks have been identified, at around ten years and 30–40 years. The peak occurs later in women than in men [24].
The symptoms can be classified in the following four main heads (Figure 1) [13].
Clinical symptoms of Moyamoya disease.
Transient ischemic attacks [TIA] and infarct may present as a variety of symptoms- motor paresis, sensory disturbance, speech disturbances, alteration of consciousness [25]. Whereas these symptoms present acutely, mental decline, dyskinesias tend to progress over the years. Dilated collateral vessels in basal ganglia have been implicated in the development of choreiform movements [26]. Bilateral disease is associated with cognitive deficits. Hemorrhagic type is more common in adults >40 years of age and most commonly present with impaired consciousness. Irrespective of the primary pathology [ischemic/hemorrhagic], the symptoms tend to be recurrent and usually a single pathology predominates in each individual. Headache is another common symptom generally seen in children <14 years old [27]. Dilated transdural collaterals stimulate dural nociceptors precipitating migraine-like headaches. Headache may also be a manifestation of chronic hypoxemia.
The symptoms are triggered by hyperventilation, such as blowing/crying due to decreased cerebral blood flow secondary to CO2 washout. Worsening is also seen with infection of the upper respiratory tract. Hypertension and aging often contribute to hemorrhage, which may occur at repetitive intervals. Massive bleeding may even lead to death. Epilepsy, as a manifestation of the disease, is usually seen in children less than ten years of age [28].
The clinical features also tend to vary from East to West. The ischemic manifestations are more predominant in the US [United States] than in other eastern countries. The rate of hemorrhagic disease in adults in Asian countries is higher [42%] than in those of Asian descent residing in the US [29]. The disorder’s overall spectrum remains constant worldwide, with ischemic manifestations as the main presenting feature in children and both ischemia and hemorrhage in adults.
Angiography is the gold standard for diagnosis and assessing disease progression. The hallmark findings of cerebral angiography are occlusion of intracranial internal carotid arteries (Figure 2) and abnormal smog-like arteriolar network [moyamoya vessels] at the base of the brain (Figure 3). The Circle of Willis and its main branches, leptomeningeal vessels and transdural anastomosis between ophthalmic artery, external carotid artery and vertebral artery are frequently seen. Involvement of posterior circulation is less commonly observed.
Neuroimaging of a 40 years old lady who presented with ICH. Non-contrast CT axial sections of brain (a, b, c) show intraventricular hemorrhage involving bilateral lateral ventricles (L > R), third and fourth ventricle. Angiographic images (d, e) show occlusion of the supraclinoid segment of the left internal carotid artery and attenuation on the right side with lenticulostriate collaterals showing a “puff of smoke” appearance (f).
Neuroimaging of a young boy of 6 years of age who presented with recurrent ischemic strokes. MRI brain axial sections show altered signal intensity areas hypointense on T1 (a) and hyperintense on T2 (b, c)) in bilateral frontoparietal cortex involving the MCA territory. Angiographic images show multiple tortuous collaterals involving both anterior (d) and posterior circulation (d, e, f) giving the typical
Suzuki et al. staged the disease progression into the following stages based on the angiographic findings [3, 22, 27].
Narrowing of the carotid forks
Initiation of moyamoya[dilated major cerebral artery and a slight network of collaterals]
Intensification of moyamoya with the disappearance of middle and anterior cerebral arteries
Minimization of moyamoya [disappearance of posterior cerebral artery and narrowing of individual moyamoya vessels]
Reduction of moyamoya [disappearance of main cerebral arteries, further minimization of moyamoya, increase in collaterals from external carotid arteries]
Disappearance of moyamoya [complete disappearance of moyamoya with blood flow derived only from the external carotid artery and vertebrobasilar system]
Apart from these changes, aneurysm formation can also be seen in angiography. A revised version of Suzuki staging system was given by Mugikura et al. (Table 1), where staging is done based on angiographic severity of stenosis of the middle cerebral artery and anterior cerebral artery [30].
ICA Stage | Angiographic findings |
---|---|
I | Mild to moderate stenosis around carotid bifurcation, absent/slightly developed moyamoya, ACA/MCA branches opacified in anterograde fashion |
II | Severe stenosis around carotid bifurcation, well developed moyamoya, several of ACA/MCA branches opacified in anterograde fashion |
III | Occlusion of proximal ACA/MCA, well developed moyamoya, only a few of ACA/MCA branches are faintly opacified in anterograde fashion through the mesh work of ICA moyamoya |
IV | Complete occlusion of proximal ACA and MCA, small amount of moyamoya, no opacification of either ACA/MCA branches in anterograde fashion |
The angiographic ICA staging system modified by Mugikura et al.
ACA- anterior cerebral artery, MCA- middle cerebral artery, ICA- internal cerebral artery.
Both the staging systems highlight that with the progression of the disease, the contribution of blood supply from ICA decreases and an intricate collateral network is formed which derives its blood flow from vessels outside the cerebral circulation.
CT scan shows hyperdensities in basal ganglia, thalamus, ventricular system and subarachnoid spaces in the hemorrhagic type of MMD. In the ischemic type of the disease, lacunar infarcts can be seen as the areas of hypodensities. When contrast-enhanced, tortuous and curvilinear vessels in basal ganglia can be visualized which represent the moyamoya vessels.
Magnetic Resonance Imaging and Angiography [MRI and MRA].
MRI and MRA provide visualization of the arterial tree without being invasive as conventional angiography. In addition to this, MRI also helps demonstrate small subcortical lesions that are difficult to identify on the CT scan. MRA helps to identify the stenotic distal end of the internal carotid artery, small moyamoya vessels and dural anastomosis between external carotid arteries and vessels of the posterior circulation.
The classification and scoring based on the MRA findings are given above in Tables 2 and 3. This MRA scoring system also finds its place in the 2012 Guidelines for the Diagnosis and Treatment of MMD in Japan [5].
Score for each artery | MRA finding |
---|---|
0 | Normal |
1 | Stenosis of C1 |
2 | Discontinuity of the C1 signal |
3 | Invisible |
0 | Normal |
1 | Stenosis of M1 |
2 | Discontinuity of the M1 signal |
3 | Invisible |
0 | Normal A2 and blood vessels distal to A2 |
1 | Signal decrease A2 and its distal blood vessels |
2 | Invisible |
0 | Normal P2 and blood vessels distal to P2 |
1 | Signal decrease P2 and its distal blood vessels |
2 | Invisible |
The classification and scoring based on the MRA findings- Score of each artery.
MRA total score | MRA stage |
---|---|
0–1 | 1 |
2–4 | 2 |
5–7 | 3 |
8–10 | 4 |
The classification and scoring based on the MRA findings – MRA total Score.
MRA: Magnetic Resonance Imaging.
In patients with moyamoya disease, the involvement of many extracranial arteries like external carotid arteries, aorta, pulmonary artery, celiac artery, and renal artery has been described. Characteristic signs like ‘ champagne bottleneck sign’ seen due to reduction in the diameter of proximal ICA and ‘diamond reversal sign’ due to smaller ICA diameter compared to external carotid artery have been demonstrated [31].
Though all the diagnostic modalities contribute to identifying and staging abnormal vasculature, angiography remains the mainstay of diagnosis. It is also helpful in documenting the postoperative resolution of moyamoya.
Electroencephalography [EEG].
The following EEG findings have been seen in moyamoya disease [32]:
Diffuse, bilateral, low voltage, slow spike and wave
‘Buildup’ phenomenon- a diffuse pattern of slow waves
‘Rebuildup’ phenomenon- diffuse slow waves during hyperventilation. This rebuild up phenomenon is seen due to decreased pCO2 on hyperventilation leading to cerebral ischemia and vasoconstriction.
The advancements in various diagnostic modalities lead to the formulation of diagnostic guidelines for Moyamoya disease shown in Table 4 [5].
A. Cerebral angiography should present at least the following findings: |
1. Stenosis/occlusion at the terminal portion of ICA and/or at the proximal portion of ACA and/or MCA |
2. Abnormal vascular network in the vicinity of stenotic/occluded vessels |
3. Bilateral findings |
B. Conventional angiogram not required when MRI/MRA demonstrate following findings:1. |
1. Stenosis/occlusion at the terminal portion of ICA and/or at the proximal portion of ACA and/or MCA on MRA |
2. Abnormal vascular network in the basal ganglia on MRA[>2 flow voids in basal ganglia in MRI]. |
3. Bilateral findings |
C. Absence of arteriosclerosis, autoimmune disease, meningitis, brain neoplasm, down syndrome, Recklinghausen’s disease, head trauma, irradiation to head, others. |
D. Pathological findings: |
1. Stenosis/occlusion due to intimal thickening at the terminal ICA, usually on both sides |
2. Arteries of Circle of Willis show varying degree of stenosis/occlusion of intima, attenuation of media and waving of internal elastic lamina |
3. Numerous small vascular channels around the Circle of Willis |
4. Reticular conglomerates of small vessels in pia matter. |
Definitive case: A/B + C[In children, a case that fulfills A1 and A2 or B1 and B2 on one side and remarkable stenosis of terminal ICA on opposite side is also included.] |
Probable case: A1 and A2 [or B1 and B2] and C [unilateral] |
Diagnostic guidelines for Moyamoya disease.
Moyamoya disease is a chronic progressive disease described earlier, leading to recurrent strokes due to internal carotid artery occlusion and ischemia due to narrow, low caliber collaterals. The illness’s mainstay is revascularization surgery to increase the intracranial blood flow using extracerebral blood vessels by direct bypass or pialsynangiosis. The decision for surgical intervention is based on the patient’s age, symptomatic/asymptomatic disease, ischemic/hemorrhagic manifestations, presence/absence of aneurysm and risk of recurrence.
The indication of surgery can be briefly summarized as follows in Figure 4 [33].
Overview of the management of Moyamoya disease.
Moyamoya disease is known to progress over the years. The disease progression rate was reported to be approximately 20% over six years in those managed conservatively [34]. The risk factors of disease progression and subsequent ischemic stroke were identified as follows:
Female gender
Graves’ disease
RNF213 variant
Family history positive [35]
Posterior circulation was also recognized as a decisive risk factor for ischemic stroke [36].
Moyamoya disease is a progressive disease, and symptomatic progression is seen in approximately two-thirds of patients [29]. In a large meta-analysis, where 1,156 people were studied, it was seen that 87% of those who underwent surgical revascularization showed partial or complete resolution of symptomatic cerebral ischemia [37].
A careful choice of treatment, that is, conservative vs. surgical should thus be made keeping in mind the above-mentioned risk factors.
The predominant manifestation of MMD is ischemic stroke. However, antiplatelet therapy is ineffective to prevent recurrent cerebral infarction in ischemic MMD. The ischemic insult in MMD patients is a consequence of hemodynamic instability. There is no evidence of endothelial dysfunction at the site of internal carotid artery bifurcation. Therefore, increased platelet adhesion is not seen in MMD. Hence, theoretically, antiplatelet drugs are ineffective for preventing ischemic stroke in MMD. Moreover, increased risk of hemorrhage remains with antiplatelets in patients with MMD [38]. The annual stroke rate in patients managed conservatively is between 3.2%–15% [35].
Surgical revascularization is done to increase the cerebral blood flow and restore reserve capacity. The increase in cerebral blood flow prevents recurrent cerebral infarction. The indications for surgical revascularization are:
Recurrent clinical symptoms due to cerebral ischemia
Pediatric MMD because pediatric MMD is more progressive than adult MMD. Early diagnosis and intervention are of paramount importance to prevent irreversible damage. In a recent study, Rosi et al. confirmed a high benefit/risk ratio, with better postoperative functional status and low rates for the need of surgical retreatment in the pediatric population undergoing surgical revascularization [39].
Role of revascularization surgery in asymptomatic MMD with stable hemodynamics is not well established but preferred by neurosurgeons given the disease being a progressive disorder. Risk–benefit ratio determines the feasibility of the surgical intervention in such patients.
Role of revascularization surgery in hemorrhagic stroke is controversial.
With increased understanding of MMD being familial in at least some of the world’s regions, it is being suggested that asymptomatic siblings and family members should be screened for moyamoya pathology. Whenever such a condition is detected, it should be managed surgically, keeping in mind the illness’s progressive nature.
Anastomosis is formed between the superficial temporal artery and cortical branches of middle cerebral arteries in this procedure. For posterior circulation, the occipital artery is used as a donor for nteroposterior cerebral arteries’ cortical branches. The transdural or transcalvarial collateral channels should be preserved during the surgery.
The advantage of this procedure is an immediate improvement in the cerebral blood flow after surgery. However, the successful restoration of cerebral blood flow is operator dependant as it is challenging to perform. Moreover, postoperative hyperperfusion syndrome may develop after surgery leading to neurological deterioration. Patency and amount of bypass flow may be assessed postoperatively by digital subtraction angiography or quantitative magnetic resonance angiography.
The annual stroke rate after direct revascularization was reportedly 0–1.6% [40].
The various surgical procedures are
Encephalomyosynangiosis[EMS] where deep temporal artery supplying the temporalis muscle is the vessel for neovascularization
Encephalo-duro-arteriosynangiosis[EDAS]: Here, superficial temporal artery[STA] is harvested with surrounding galea and periosteum; STA flap is placed with a galea cuff. The dura and galea are then sutured to cover the brain with arterial flap.
Encephalo-myo-arteriosynangiosis[EDAMS]
Encephalo-galeo-synangiosis[EGS]
Omental flap surgery
Multiple burr hole surgery
The last two surgeries are performed as primary or after failed revascularization by other techniques.
Indirect revascularization is relatively easier to perform than direct surgeries, and the incidence of hyperperfusion is also less. However, the improvement in cerebral revascularization takes longer than the direct surgeries where the effect is immediate.
After indirect revascularization, patients experienced 0–14.3% postoperative annual stroke rate [41].
Thus either of the indirect and direct revascularization procedures can be performed to rectify the underlying pathology, but the risk of recurrence is much less with the direct revascularization surgeries without any delay to the benefit.
The following complications have been noted in the peri/postoperative period in MMD:
The risk of postoperative stroke has been estimated to be 1.6%- 16% [42].
The risk of perioperative ischemic complications is more in patients with unstable hemodynamics and advanced Suzuki stage with a lower cerebral blood flow.
Hemorrhagic stroke develops in 0.7%–8% [42].
Hyperperfusion syndrome- due to the chronic changes in cerebral blood vessels, the auto-regulatory function is lost, and the vascular reserve is decreased. The excessive blood flow immediately after the surgery is sometimes not well tolerated, leading to cerebral hemorrhage. Another factor that may predispose to intracranial hemorrhage is increased vascular permeability secondary to chronic ischemia.
Epidural hematoma mainly in the pediatric population.
Skin problems due to scalp ischemia after revascularization.
Moyamoya disease is a chronic progressive vasculopathy seen in children and adults, characterized by occlusion/stenosis at the terminal portions of the internal carotid artery and abnormal collateral network formation at the base of the brain. It is predominantly seen in Asian countries. It may be idiopathic [moyamoya disease] or associated with other disorders when it is called moyamoya syndrome. Various angiographic and magnetic resonance angiographic findings have been described which form the basis of the diagnostic guidelines for MMD. It may present as an ischemic/hemorrhagic stroke. It is generally managed with direct/indirect revascularization surgical techniques that aim to restore the cerebral blood flow and prevent strokes that restore the cerebral blood flow and prevent strokes’ recurrence.
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\r\n\r\nFor a quote or assistance please contact us directly at orders@intechopen.com The quote will be sent to you within 1-2 business days.
\r\n\r\nOur entire portfolio of over 5,500 books is also available through Amazon.
',metaTitle:"Order and delivery",metaDescription:"Our books are published online and are accessible for free. However, if you are interested in ordering your hardcover copy, you can do so by contacting our Print Sales Department at orders@intechopen.com. All IntechOpen books are printed on demand in full-colour and delivered in signature packaging through free DHL Express delivery. A selection of our books in soft cover is also available through Amazon.",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"Our books are available hardcover, printed in full colour and produced to the highest standards on PEFC™ and FSC certified paper, complying with principles of responsible forestry worldwide. The paper size is 180 x 260 mm (7 x 10.2 inches).
\\n\\nIntechOpen works with award winning print-houses and we hold to the fact that all of our printed products are of the highest quality.
\\n\\nIntechOpen books retail price range is:
\\n\\n100 - 159 GBP ex. VAT (available in USD and EUR)
\\n\\nDiscounts available:
\\n\\nBulk discounts are granted for orders of 10 copies and more.
\\n\\nThere is no minimum or maximum threshold on the quantity of book orders.
\\n\\nOrders have to be paid in advance and before printing. We accept payment in GBP, EUR and USD.
\\n\\nWe currently accept the following payment options:
\\n\\nWhen paying with a credit card, you will be redirected to the PayPal.com online payment portal.
\\n\\nIntechOpen will help you complete your payment safely and securely, keeping your personal, professional and financial information safe.
\\n\\nIn accordance with the best security practice, we do not accept card orders via email.
\\n\\nThe combined printing and delivery time for orders vary from 7-15 business days, depending on the printed quantity and destination. This period does not include any customs clearance difficulties that may arise and that are beyond our control. Once your order has been printed and shipped, you will receive a confirmation email that includes your DHL tracking number. You can then track your order at www.dhl.com.
\\n\\nIf you do not receive your order within 30 days from the date your order is shipped, please contact us to inquire about the shipping status at orders@intechopen.com.
\\n\\nTax: Residents of European Union countries need to add a Book Value-Added Tax Rate based on their country of residence. Institutions and companies, registered as VAT taxable entities in their own EU member state, will not pay VAT by providing IntechOpen with their VAT registration number. This is made possible by the EU reverse charge method.
\\n\\nCustoms: free shipping does not include any duties, taxes or clearing charges levied by the destination country. These charges are the responsibility of the customer and will vary from country to country.
\\n\\nP.O. Boxes cannot be used as a Ship-To Address.
\\n\\nIntechOpen partners do not provide shipping service from Europe to the countries listed below. Please refrain from mailing items addressed to the countries listed below, until further notice.
\\n\\nWhen ordering our books from the countries listed below, please provide an alternative mailing address. For any further assistance, please contact us at orders@intechopen.com.
\\n\\nRestricted Ship-to Countries:
\\n\\nPOD products are non-returnable and non-refundable, except in the event of poor print quality or an error in quantity. If we delivered the item to you in error or the item is faulty, please contact us.
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\\n\\nPrint copies of our publications are most often purchased by universities, libraries, institutions and academia personnel, hence increasing the visibility and outreach of our authors' published work among science communities and institutions.
\\n\\nOur books are available at our direct Print Sales Department and through selected representatives throughout the world.
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\\n\\nChina Publishers Services Ltd - CPS
\\n\\nRepresentative for: China, Taiwan, Hong Kong
\\n\\nIndia - CBS Publishers & Distributors Pvt. Ltd.
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\\n\\nLSR Libros Servicios y Representaciones S.A. de C.V
\\n\\nRepresentative for Mexico, Chile and Colombia
\\n\\nMissing Link Versandbuchhandlung eG
\\n\\nRepresentative for: Germany, Austria, Switzerland
\\n\\nKuba Libri, s.r.o.
\\n\\nRepresentative for: Czech Republic
\\n\\nFor partnership opportunities, please contact orders@intechopen.com.
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\n\nIntechOpen works with award winning print-houses and we hold to the fact that all of our printed products are of the highest quality.
\n\nIntechOpen books retail price range is:
\n\n100 - 159 GBP ex. VAT (available in USD and EUR)
\n\nDiscounts available:
\n\nBulk discounts are granted for orders of 10 copies and more.
\n\nThere is no minimum or maximum threshold on the quantity of book orders.
\n\nOrders have to be paid in advance and before printing. We accept payment in GBP, EUR and USD.
\n\nWe currently accept the following payment options:
\n\nWhen paying with a credit card, you will be redirected to the PayPal.com online payment portal.
\n\nIntechOpen will help you complete your payment safely and securely, keeping your personal, professional and financial information safe.
\n\nIn accordance with the best security practice, we do not accept card orders via email.
\n\nThe combined printing and delivery time for orders vary from 7-15 business days, depending on the printed quantity and destination. This period does not include any customs clearance difficulties that may arise and that are beyond our control. Once your order has been printed and shipped, you will receive a confirmation email that includes your DHL tracking number. You can then track your order at www.dhl.com.
\n\nIf you do not receive your order within 30 days from the date your order is shipped, please contact us to inquire about the shipping status at orders@intechopen.com.
\n\nTax: Residents of European Union countries need to add a Book Value-Added Tax Rate based on their country of residence. Institutions and companies, registered as VAT taxable entities in their own EU member state, will not pay VAT by providing IntechOpen with their VAT registration number. This is made possible by the EU reverse charge method.
\n\nCustoms: free shipping does not include any duties, taxes or clearing charges levied by the destination country. These charges are the responsibility of the customer and will vary from country to country.
\n\nP.O. Boxes cannot be used as a Ship-To Address.
\n\nIntechOpen partners do not provide shipping service from Europe to the countries listed below. Please refrain from mailing items addressed to the countries listed below, until further notice.
\n\nWhen ordering our books from the countries listed below, please provide an alternative mailing address. For any further assistance, please contact us at orders@intechopen.com.
\n\nRestricted Ship-to Countries:
\n\nPOD products are non-returnable and non-refundable, except in the event of poor print quality or an error in quantity. If we delivered the item to you in error or the item is faulty, please contact us.
\n\nInspect your order carefully when it arrives. Any problems should be immediately reported to orders@intechopen.com.
\n\nPrint copies of our publications are most often purchased by universities, libraries, institutions and academia personnel, hence increasing the visibility and outreach of our authors' published work among science communities and institutions.
\n\nOur books are available at our direct Print Sales Department and through selected representatives throughout the world.
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\n\nRepresentative for: Brunei, Cambodia, Indonesia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, Vietnam (ASEAN)
\n\nChina Publishers Services Ltd - CPS
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\n\nIndia - CBS Publishers & Distributors Pvt. Ltd.
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\n\nRepresentative for Mexico, Chile and Colombia
\n\nMissing Link Versandbuchhandlung eG
\n\nRepresentative for: Germany, Austria, Switzerland
\n\nKuba Libri, s.r.o.
\n\nRepresentative for: Czech Republic
\n\nFor partnership opportunities, please contact orders@intechopen.com.
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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. 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