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Sakoda K, Baba S. Technical Note: Novel imaging method to obtain gray matter-attenuated inversion recovery image using low-field magnetic resonance imaging systems. Radiography (Lond) 2024; 30:231-236. [PMID: 38035438 DOI: 10.1016/j.radi.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/16/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION The double inversion recovery (DIR) technique suppresses two types of tissue signals with different T1 values by applying two inversion recovery (IR) pulses with different inversion times (TI). In contrast, the double tissue suppression with multi-echo acquisition and single TI combining HIRE (DOMUST-HIRE) method, is a technique enabling the white-matter-attenuated inversion recovery (WAIR) images by setting one inversion time (TI) in a sequence based on the multi-echo method and subtracting the second echo image from the first echo image. Here, we propose a new sequence that can provide the gray-matter-attenuated inversion recovery image based on the DOMUST-HIRE method. METHODS In this small clinical study, we performed determination of optimal TI and physical evaluation by imaging a subject's head with T1WI and our proposed method for GAIR images. RESULTS Our proposed method could increase the contrast ratio and the contrast-to-noise ratio between white matter (WM) and gray matter (GM), whereas the signal-to-noise ratio WM and GM decreased than with T1WI method. CONCLUSIONS Our proposed method can be used to suppress GM and CSF signals. IMPLICATIONS FOR PRACTICE The use of our proposed method in low-field MRI systems could provide GAIR image.
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Affiliation(s)
- K Sakoda
- Department of Radiological Technology, Kagoshima Medical Technology College, Japan.
| | - S Baba
- Department of Radiological Technology, Kagoshima Medical Technology College, Japan
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Lebrun-Frenay C, Kantarci O, Siva A, Azevedo CJ, Makhani N, Pelletier D, Okuda DT. Radiologically isolated syndrome. Lancet Neurol 2023; 22:1075-1086. [PMID: 37839432 DOI: 10.1016/s1474-4422(23)00281-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/29/2023] [Accepted: 07/17/2023] [Indexed: 10/17/2023]
Abstract
Individuals can be deemed to have radiologically isolated syndrome (RIS) if they have incidental demyelinating-appearing lesions in their brain or spinal cord that are highly suggestive of multiple sclerosis but their clinical history does not include symptoms consistent with multiple sclerosis. Data from international longitudinal cohorts indicate that around half of people with RIS will develop relapsing or progressive symptoms of multiple sclerosis within 10 years, suggesting that in some individuals, RIS is a presymptomatic stage of multiple sclerosis. Risk factors for progression from RIS to clinical multiple sclerosis include younger age (ie, <35 years), male sex, CSF-restricted oligoclonal bands, spinal cord or infratentorial lesions, and gadolinium-enhancing lesions. Other imaging, biological, genetic, and digital biomarkers that might be of value in identifying individuals who are at the highest risk of developing multiple sclerosis need further investigation. Two 2-year randomised clinical trials showed the efficacy of approved multiple sclerosis immunomodulatory medications in preventing the clinical conversion to multiple sclerosis in some individuals with RIS. If substantiated in longer-term studies, these data have the potential to transform our approach to care for the people with RIS who are at the greatest risk of diagnosis with multiple sclerosis.
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Affiliation(s)
- Christine Lebrun-Frenay
- CRC-SEP Nice, Neurologie CHU Nice, Hôpital Pasteur 2, UMR2CA-URRIS, Université Côte d'Azur, Nice, France.
| | | | - Aksel Siva
- Department of Neurology, Cerrahpasa School of Medicine, Istanbul University, Turkiye
| | - Christina J Azevedo
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Naila Makhani
- Departments of Pediatrics and Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Daniel Pelletier
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Darin T Okuda
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kalinowska-Lyszczarz A, Tillema JM, Tobin WO, Guo Y, Weigand SD, Metz I, Brück W, Lassmann H, Giraldo-Chica M, Port JD, Lucchinetti CF. Long-term clinical, imaging and cognitive outcomes association with MS immunopathology. Ann Clin Transl Neurol 2023; 10:339-352. [PMID: 36759436 PMCID: PMC10014012 DOI: 10.1002/acn3.51723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/16/2022] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVE In this observational study on a cohort of biopsy-proven central nervous system demyelinating disease consistent with MS, we examined the relationship between early-active demyelinating lesion immunopattern (IP) with subsequent clinical course, radiographic progression, and cognitive function. METHODS Seventy-five patients had at least one early-active lesion on biopsy and were pathologically classified into three immunopatterns based on published criteria. The median time from biopsy at follow-up was 11 years, median age at biopsy - 41, EDSS - 4.0. At last follow-up, the median age was 50, EDSS - 3.0. Clinical examination, cognitive assessment (CogState battery), and 3-Tesla-MRI (MPRAGE/FLAIR/T2/DIR/PSIR/DTI) were obtained. RESULTS IP-I was identified in 14/75 (19%), IP-II was identified in 41/75 (56%), and IP-III was identified in 18/75 (25%) patients. Patients did not differ significantly by immunopattern in clinical measures at onset or last follow-up. The proportions of disease courses after a median of 11 years were similar across immunopatterns, relapsing-remitting being most common (63%), followed by monophasic (32%). No differences in volumetric or DTI measures were found. CogState performance was similar for most tasks. A slight yet statistically significant difference was identified for episodic memory scores, with IP-III patients recalling one word less on average. INTERPRETATION In this study, immunopathological heterogeneity of early-active MS lesions identified at biopsy does not correlate with different long-term clinical, neuroimaging or cognitive outcomes. This could be explained by the fact that while active white matter lesions are pathological substrates for relapses, MS progression is driven by mechanisms converging across immunopatterns, regardless of pathogenic mechanisms driving the acute demyelinated plaque.
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Affiliation(s)
- Alicja Kalinowska-Lyszczarz
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Division of Neurochemistry and Neuropathology, Poznan University of Medical Sciences, Poznan, Poland
| | | | | | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephen D Weigand
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Imke Metz
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center, Göttingen, Germany
| | - Hans Lassmann
- Center for Brain Research, Medical University of Vienna, Wien, Austria
| | - Monica Giraldo-Chica
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John D Port
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Meaton I, Altokhis A, Allen CM, Clarke MA, Sinnecker T, Meier D, Enzinger C, Calabrese M, De Stefano N, Pitiot A, Giorgio A, Schoonheim MM, Paul F, Pawlak MA, Schmidt R, Granziera C, Kappos L, Montalban X, Rovira À, Wuerfel J, Evangelou N. Paramagnetic rims are a promising diagnostic imaging biomarker in multiple sclerosis. Mult Scler 2022; 28:2212-2220. [PMID: 36017870 DOI: 10.1177/13524585221118677] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND White matter lesions (WMLs) on brain magnetic resonance imaging (MRI) in multiple sclerosis (MS) may contribute to misdiagnosis. In chronic active lesions, peripheral iron-laden macrophages appear as paramagnetic rim lesions (PRLs). OBJECTIVE To evaluate the sensitivity and specificity of PRLs in differentiating MS from mimics using clinical 3T MRI scanners. METHOD This retrospective international study reviewed MRI scans of patients with MS (n = 254), MS mimics (n = 91) and older healthy controls (n = 217). WMLs, detected using fluid-attenuated inversion recovery MRI, were analysed with phase-sensitive imaging. Sensitivity and specificity were assessed for PRLs. RESULTS At least one PRL was found in 22.9% of MS and 26.1% of clinically isolated syndrome (CIS) patients. Only one PRL was found elsewhere. The identification of ⩾1 PRL was the optimal cut-off and had high specificity (99.7%, confidence interval (CI) = 98.20%-99.99%) when distinguishing MS and CIS from mimics and healthy controls, but lower sensitivity (24.0%, CI = 18.9%-36.6%). All patients with a PRL showing a central vein sign (CVS) in the same lesion (n = 54) had MS or CIS, giving a specificity of 100% (CI = 98.8%-100.0%) but equally low sensitivity (21.3%, CI = 16.4%-26.81%). CONCLUSION PRLs may reduce diagnostic uncertainty in MS by being a highly specific imaging diagnostic biomarker, especially when used in conjunction with the CVS.
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Affiliation(s)
- Isobel Meaton
- Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amjad Altokhis
- Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christopher Martin Allen
- Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Margareta A Clarke
- Institute of Imaging Science, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Tim Sinnecker
- Medical Image Analysis Center AG and Department of Biomedical Engineering, University Basel, Basel, Switzerland
| | - Dominik Meier
- Medical Image Analysis Center AG and Department of Biomedical Engineering, University Basel, Basel, Switzerland
| | | | - Massimiliano Calabrese
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Nicola De Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Alain Pitiot
- Laboratory of Image and Data Analysis, Ilixa Ltd, London, UK
| | - Antonio Giorgio
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Menno M Schoonheim
- Department of Anatomy and Neurosciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Friedemann Paul
- Neurocure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Mikolaj A Pawlak
- Department of Neurology and Cerebrovascular Disorders, Poznan University of Medical Sciences, Poznan, Poland
| | - Reinhold Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Cristina Granziera
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Xavier Montalban
- Centre d'Esclerosi Multiple de Catalunya (Cemcat), Department of Neurology/Neuroimmunology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Àlex Rovira
- Section of Neuroradiology, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jens Wuerfel
- Medical Image Analysis Center AG and Department of Biomedical Engineering, University Basel, Basel, Switzerland/Neurocure Clinical Research Center, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Nikos Evangelou
- Mental Health and Clinical Neurosciences Academic Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Kalinowska-Lyszczarz A, Tillema JM, Tobin WO, Guo Y, Fitz-Gibbon PD, Weigand SD, Giraldo-Chica M, Port JD, Lucchinetti CF. Long-term clinical, MRI, and cognitive follow-up in a large cohort of pathologically confirmed, predominantly tumefactive multiple sclerosis. Mult Scler 2021; 28:441-452. [PMID: 34212755 DOI: 10.1177/13524585211024162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited studies have described long-term outcomes in pathology confirmed multiple sclerosis (MS). OBJECTIVES To describe long-term clinical-radiographic-cognitive outcomes in a prospectively followed cohort of patients with pathologically confirmed CNS demyelinating disease, consistent with MS. METHODS Subjects underwent clinical assessment, standardized 3T-MRI brain, and cognitive battery. RESULTS Seventy-five patients were included. Biopsied lesion size was ⩾ 2 cm in 62/75. At follow-up, median duration since biopsy was 11 years. Median EDSS was 3 and lesion burden was large (median 10 cm3). At follow-up, 57/75 met MS criteria, 17/75 had clinically isolated syndrome, and 1 radiographic changes only. Disability scores were comparable to a prevalence cohort in Olmsted County (p < 0.001, n = 218). Cognitive outcomes below age-normed standards included psychomotor, attention, working memory, and executive function domains. Total lesion volume and index lesion-related severity correlated with EDSS and cognitive performance. Volumetric cortical/subcortical GM correlated less than lesion metrics to cognitive outcomes. CONCLUSION Despite early aggressive course in pathologically confirmed MS, its long-term course was comparable to typical MS in our study. Cognitive impairment in this group seemed to correlate strongest to index lesion severity and total lesion volume. It remains to be established how the aggressive nature of the lesion, biopsy, and treatment affect clinical/cognitive outcomes.
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Affiliation(s)
- Alicja Kalinowska-Lyszczarz
- Department of Neurology, Mayo Clinic, Rochester, MN, USA/Department of Neurology, Poznań University of Medical Sciences, Poznań, Poland
| | | | - W Oliver Tobin
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Stephen D Weigand
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - John D Port
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Crescenzo F, Marastoni D, Pisani AI, Tamanti A, Dapor C, Colombi A, Brillo A, Magliozzi R, Pizzini FB, Castellaro M, Calabrese M. The Prognostic Value of White-Matter Selective Double Inversion Recovery MRI Sequence in Multiple Sclerosis: An Exploratory Study. Diagnostics (Basel) 2021; 11:diagnostics11040686. [PMID: 33921278 PMCID: PMC8069390 DOI: 10.3390/diagnostics11040686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022] Open
Abstract
Using a white-matter selective double inversion recovery sequence (WM-DIR) that suppresses both grey matter (GM) and cerebrospinal fluid (CSF) signals, some white matter (WM) lesions appear surrounded by a dark rim. These dark rim lesions (DRLs) seem to be specific for multiple sclerosis (MS). They could be of great usefulness in clinical practice, proving to increase the MRI diagnostic criteria specificity. The aims of this study are the identification of DRLs on 1.5 T MRI, the exploration of the relationship between DRLs and disease course, the characterization of DRLs with respect to perilesional normal-appearing WM using magnetization transfer imaging, and the investigation of possible differences in the underlying tissue properties by assessing WM-DIR images obtained at 3.0 T MRI. DRLs are frequent in primary progressive MS (PPMS) patients. Amongst relapsing-remitting MS (RRMS) patients, DRLs are associated with a high risk of the disease worsening and secondary progressive MS (SPMS) conversion after 15 years. The mean magnetization transfer ratio (MTR) of DRLs is significantly different from the lesion without the dark rim, suggesting that DRLs correspond to more destructive lesions.
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Affiliation(s)
- Francesco Crescenzo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
- Neurology Unit, Mater Salutis Hospital, Legnago, 37045 Verona, Italy
| | - Damiano Marastoni
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Anna Isabella Pisani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Agnese Tamanti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Caterina Dapor
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Annalisa Colombi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Alessandro Brillo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Roberta Magliozzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | | | - Marco Castellaro
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
| | - Massimiliano Calabrese
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134 Verona, Italy; (F.C.); (D.M.); (A.I.P.); (A.T.); (C.D.); (A.C.); (A.B.); (R.M.); (M.C.)
- Correspondence:
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AlTokhis AI, AlOtaibi AM, Felmban GA, Constantinescu CS, Evangelou N. Iron Rims as an Imaging Biomarker in MS: A Systematic Mapping Review. Diagnostics (Basel) 2020; 10:diagnostics10110968. [PMID: 33218056 PMCID: PMC7698946 DOI: 10.3390/diagnostics10110968] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Multiple sclerosis (MS) is an autoimmune, inflammatory, demyelinating and degenerative disease of the central nervous system (CNS). To date, there is no definitive imaging biomarker for diagnosing MS. The current diagnostic criteria are mainly based on clinical relapses supported by the presence of white matter lesions (WMLs) on MRI. However, misdiagnosis of MS is still a significant clinical problem. The paramagnetic, iron rims (IRs) around white matter lesions have been proposed to be an imaging biomarker in MS. This study aimed to carry out a systematic mapping review to explore the detection of iron rim lesions (IRLs), on clinical MR scans, and describe the characteristics of IRLs presence in MS versus other MS-mimic disorders. Methods: Publications from 2001 on IRs lesions were reviewed in three databases: PubMed, Web of Science and Embase. From the initial result set 718 publications, a final total of 38 papers were selected. Results: The study revealed an increasing interest in iron/paramagnetic rims lesions studies. IRs were more frequently found in periventricular regions and appear to be absent in MS-mimics. Conclusions IR is proposed as a promising imaging biomarker for MS.
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Affiliation(s)
- Amjad I. AlTokhis
- School of Medicine, University of Nottingham, Nottingham, UK/Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; (A.M.A.); (G.A.F.); (C.S.C.); (N.E.)
- School of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
- Correspondence:
| | - Abdulmajeed M. AlOtaibi
- School of Medicine, University of Nottingham, Nottingham, UK/Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; (A.M.A.); (G.A.F.); (C.S.C.); (N.E.)
- School of Applied Medical Sciences, King Saud bin Abdulaziz University, Riyadh 14611, Saudi Arabia
| | - Ghadah A. Felmban
- School of Medicine, University of Nottingham, Nottingham, UK/Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; (A.M.A.); (G.A.F.); (C.S.C.); (N.E.)
- School of Applied Medical Sciences, King Saud bin Abdulaziz University, Riyadh 14611, Saudi Arabia
| | - Cris S. Constantinescu
- School of Medicine, University of Nottingham, Nottingham, UK/Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; (A.M.A.); (G.A.F.); (C.S.C.); (N.E.)
| | - Nikos Evangelou
- School of Medicine, University of Nottingham, Nottingham, UK/Division of Clinical Neuroscience, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; (A.M.A.); (G.A.F.); (C.S.C.); (N.E.)
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Affiliation(s)
- John D Port
- From the Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Mayo West 2, Rochester, MN 55905
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