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Andrews L, Keller SS, Osman-Farah J, Macerollo A. A structural magnetic resonance imaging review of clinical motor outcomes from deep brain stimulation in movement disorders. Brain Commun 2023; 5:fcad171. [PMID: 37304793 PMCID: PMC10257440 DOI: 10.1093/braincomms/fcad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 04/05/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023] Open
Abstract
Patients with movement disorders treated by deep brain stimulation do not always achieve successful therapeutic alleviation of motor symptoms, even in cases where surgery is without complications. Magnetic resonance imaging (MRI) offers methods to investigate structural brain-related factors that may be predictive of clinical motor outcomes. This review aimed to identify features which have been associated with variability in clinical post-operative motor outcomes in patients with Parkinson's disease, dystonia, and essential tremor from structural MRI modalities. We performed a literature search for articles published between 1 January 2000 and 1 April 2022 and identified 5197 articles. Following screening through our inclusion criteria, we identified 60 total studies (39 = Parkinson's disease, 11 = dystonia syndromes and 10 = essential tremor). The review captured a range of structural MRI methods and analysis techniques used to identify factors related to clinical post-operative motor outcomes from deep brain stimulation. Morphometric markers, including volume and cortical thickness were commonly identified in studies focused on patients with Parkinson's disease and dystonia syndromes. Reduced metrics in basal ganglia, sensorimotor and frontal regions showed frequent associations with reduced motor outcomes. Increased structural connectivity to subcortical nuclei, sensorimotor and frontal regions was also associated with greater motor outcomes. In patients with tremor, increased structural connectivity to the cerebellum and cortical motor regions showed high prevalence across studies for greater clinical motor outcomes. In addition, we highlight conceptual issues for studies assessing clinical response with structural MRI and discuss future approaches towards optimizing individualized therapeutic benefits. Although quantitative MRI markers are in their infancy for clinical purposes in movement disorder treatments, structural features obtained from MRI offer the powerful potential to identify candidates who are more likely to benefit from deep brain stimulation and provide insight into the complexity of disorder pathophysiology.
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Affiliation(s)
- Luke Andrews
- The Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L3 9TA, UK
- Department of Neurology and Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L97LJ, UK
| | - Simon S Keller
- The Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L3 9TA, UK
| | - Jibril Osman-Farah
- Department of Neurology and Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L97LJ, UK
| | - Antonella Macerollo
- The Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L3 9TA, UK
- Department of Neurology and Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L97LJ, UK
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Zhao W, Yang C, Tong R, Chen L, Chen M, Gillen KM, Li G, Ma C, Wang Y, Wu X, Li J. Relationship Between Iron Distribution in Deep Gray Matter Nuclei Measured by Quantitative Susceptibility Mapping and Motor Outcome After Deep Brain Stimulation in Patients With Parkinson's Disease. J Magn Reson Imaging 2023. [PMID: 36594513 DOI: 10.1002/jmri.28574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor deficits in advanced Parkinson's disease (PD) patients, but the degree of motor improvement varies across individuals. PD pathology involves the changes of iron spatial distribution in the deep gray matter nuclei. PURPOSE To explore the relationship between the iron spatial distribution and motor improvement among PD patients who underwent STN-DBS surgery in three regions: substantia nigra (SN), STN, and dentate nucleus (DN). STUDY TYPE Prospective. SUBJECTS Forty PD patients (49.7 ± 8.8 years, 22 males/18 females) who underwent bilateral STN-DBS. FIELD STRENGTH/SEQUENCE A 3 T preoperative three-dimensional spoiled bipolar-readout multi-echo gradient recalled echo and two-dimensional fast spin echo sequences. ASSESSMENT Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS III) scores were assessed 2-3 days before and 6 months after STN-DBS. The first- and second-order texture features in regions of interest were measured on susceptibility maps. STATISTICAL TESTS Intraclass correlation coefficient was used to determine the consistency of the region of interest volumes delineated by the two raters. Pearson or Spearman's correlation coefficients were used to assess the relationship between motor improvement after DBS and texture features. A P-value <0.05 was considered statistically significant. RESULTS MDS-UPDRS III scores were reduced by 59.9% after STN-DBS in 40 PD patients. Motor improvement correlated with second-order texture parameters in the SN including angular second moment (r = -0.449), correlation (rho = 0.326), sum of squares (r = 0.402), sum of entropy (rho = 0.421), and entropy (r = 0.410). Additionally, DBS outcome negatively correlated with mean susceptibility values in the DN (r = -0.400). DATA CONCLUSION PD patients with a more homogeneous iron distribution throughout the SN or a higher iron concentration in the DN responded worse to STN-DBS. LEVEL OF EVIDENCE 2 TECHNICAL EFFICACY: Stage 1.
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Affiliation(s)
- Weiwei Zhao
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Chunhui Yang
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Rui Tong
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Luguang Chen
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Mengying Chen
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Kelly M Gillen
- Department of Radiology, Weill Medical College of Cornell University, New York, New York, USA
| | - Gaiying Li
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
| | - Chao Ma
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Yi Wang
- Department of Radiology, Weill Medical College of Cornell University, New York, New York, USA
| | - Xi Wu
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Jianqi Li
- Shanghai Key Laboratory of Magnetic Resonance, School of Physics and Electronic Science, East China Normal University, Shanghai, China
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Wang F, Lai Y, Pan Y, Li H, Liu Q, Sun B. A systematic review of brain morphometry related to deep brain stimulation outcome in Parkinson's disease. NPJ Parkinsons Dis 2022; 8:130. [PMID: 36224189 PMCID: PMC9556527 DOI: 10.1038/s41531-022-00403-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
While the efficacy of deep brain stimulation (DBS) is well-established in Parkinson’s Disease (PD), the benefit of DBS varies across patients. Using imaging features for outcome prediction offers potential in improving effectiveness, whereas the value of presurgical brain morphometry, derived from the routinely used imaging modality in surgical planning, remains under-explored. This review provides a comprehensive investigation of links between DBS outcomes and brain morphometry features in PD. We systematically searched PubMed and Embase databases and retrieved 793 articles, of which 25 met inclusion criteria and were reviewed in detail. A majority of studies (24/25), including 1253 of 1316 patients, focused on the outcome of DBS targeting the subthalamic nucleus (STN), while five studies included 57 patients receiving globus pallidus internus (GPi) DBS. Accumulated evidence showed that the atrophy of motor cortex and thalamus were associated with poor motor improvement, other structures such as the lateral-occipital cortex and anterior cingulate were also reported to correlated with motor outcome. Regarding non-motor outcomes, decreased volume of the hippocampus was reported to correlate with poor cognitive outcomes. Structures such as the thalamus, nucleus accumbens, and nucleus of basalis of Meynert were also reported to correlate with cognitive functions. Caudal middle frontal cortex was reported to have an impact on postsurgical psychiatric changes. Collectively, the findings of this review emphasize the utility of brain morphometry in outcome prediction of DBS for PD. Future efforts are needed to validate the findings and demonstrate the feasibility of brain morphometry in larger cohorts.
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Affiliation(s)
- Fengting Wang
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijie Lai
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yixin Pan
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongyang Li
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qimin Liu
- grid.152326.10000 0001 2264 7217Department of Psychology and Human Development, Vanderbilt University, Nashville, USA
| | - Bomin Sun
- grid.16821.3c0000 0004 0368 8293Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Frizon LA, Gopalakrishnan R, Hogue O, Floden D, Nagel SJ, Baker KB, Isolan GR, Stefani MA, Machado AG. Cortical thickness in visuo-motor areas is related to motor outcomes after STN DBS for Parkinson's disease. Parkinsonism Relat Disord 2020; 71:17-22. [PMID: 31978672 DOI: 10.1016/j.parkreldis.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/07/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a widely accepted therapy for Parkinson's disease. While outcome predictors such as levodopa-response are well established, there remains a need for objective and unbiased predictors in clinical practice. We performed an exploratory study to examine whether cortical thickness, derived from preoperative MRI, correlates with postoperative outcome. METHODS Using freesurfer, we retrospectively measured cortical thickness on the preoperative MRI of 38 patients who underwent bilateral STN-DBS for PD during a 4-year period. The Unified Parkinson Disease Rating motor (UPDRS III) and experiences of daily living subscales (UPDRS II) were collected at baseline and six months after surgery. As an initial analysis, a series of partial correlations was conducted to evaluate the association between postoperative outcome scores and average cortical thickness from predefined regions of interest, adjusting for candidate confounders, without correcting for multiple comparisons. A confirmatory vertex-wise analysis was performed using a cluster-wise correction for multiple comparisons. RESULTS Based on the ROI analysis, the strongest correlation with motor outcome was found to be with the left lateral-occipital cortex. Patients with greater cortical thickness in this area presented with greater improvements in motor scores. This relationship was also supported by the vertex-wise analysis. Greater cortical thickness in frontal and temporal regions may be correlated with greater post-operative improvements in UPDRS II, but this was not confirmed in the vertex-wise analysis. CONCLUSIONS Our data indicate that greater cortical thickness in visuo-motor areas is correlated with motor outcomes after DBS for PD. Further prospective investigations are needed to confirm our findings and better-investigate potential image biomarkers.
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Affiliation(s)
- Leonardo A Frizon
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Raghavan Gopalakrishnan
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olivia Hogue
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Darlene Floden
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth B Baker
- Department of Neuroscience, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA; Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gustavo R Isolan
- Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Marco A Stefani
- Post-graduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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Aging of cerebral white matter. Ageing Res Rev 2017; 34:64-76. [PMID: 27865980 DOI: 10.1016/j.arr.2016.11.006] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/21/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022]
Abstract
White matter (WM) occupies a large volume of the human cerebrum and is mainly composed of myelinated axons and myelin-producing glial cells. The myelinated axons within WM are the structural foundation for efficient neurotransmission between cortical and subcortical areas. Similar to neuron-enriched gray matter areas, WM undergoes a series of changes during the process of aging. WM malfunction can induce serious neurobehavioral and cognitive impairments. Thus, age-related changes in WM may contribute to the functional decline observed in the elderly. In addition, aged WM becomes more susceptible to neurological disorders, such as stroke, traumatic brain injury (TBI), and neurodegeneration. In this review, we summarize the structural and functional alterations of WM in natural aging and speculate on the underlying mechanisms. We also discuss how age-related WM changes influence the progression of various brain disorders, including ischemic and hemorrhagic stroke, TBI, Alzheimer's disease, and Parkinson's disease. Although the physiology of WM is still poorly understood relative to gray matter, WM is a rational therapeutic target for a number of neurological and psychiatric conditions.
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Hamasaki T, Yamada K, Kitajima M, Kuratsu JI. Flatness of the infratentorial space associated with hemifacial spasm. Acta Neurochir (Wien) 2016; 158:1405-12. [PMID: 27179978 DOI: 10.1007/s00701-016-2831-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/28/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whether a difference in morphology of the infratentorial space is associated with hemifacial spasm is not well understood. The aim of this study was to analyze the three-dimensional conformation of the infratentorial space and evaluate any possible contribution of morphological characteristics to the development of neurovascular compression leading to hemifacial spasm. METHODS We enrolled 25 patients with hemifacial spasm and matched them by age and sex to controls. The extent of the three-dimensional axes and the volume of the infratentorial space were measured using image analysis software for three-dimensional MRI. We evaluated the correlation between a morphological difference in the infratentorial space and changes in vascular configuration in the brain stem. RESULTS We found no statistical difference in volumetric analyses. The mean aspect ratio on the coronal plane (the ratio of the Z to X extent) of the infratentorial space in patients with hemifacial spasm was significantly lower (p < 0.01) than that in controls, as was the mean aspect ratio on the sagittal plane (the ratio of Z to Y extent, p < 0.01). A smaller sagittal aspect ratio was correlated (p < 0.05) with greater lateral deviation of the basilar artery. CONCLUSIONS Our results suggest that flatness of the superior-inferior dimension of the infratentorial space is an anatomical feature that characterizes patients with hemifacial spasm. We hypothesize that this unique structural variation may exaggerate the lateral deviation of the vertebrobasilar arteries due to arteriosclerosis and exacerbate the space competition among vessels and cranial nerves.
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Affiliation(s)
- Tadashi Hamasaki
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Kazumichi Yamada
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Mika Kitajima
- Department of Diagnostic Radiology, Kumamoto University Medical School, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Jun-Ichi Kuratsu
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1, Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
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Hamasaki T, Hirai T, Yamada K, Kuratsu JI. An in vivo morphometry study on the standard transsylvian trajectory for mesial temporal lobe epilepsy surgery. SPRINGERPLUS 2015; 4:406. [PMID: 26266077 PMCID: PMC4529845 DOI: 10.1186/s40064-015-1198-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 07/29/2015] [Indexed: 11/24/2022]
Abstract
A safe and appropriate surgical approach to the medial temporal structure is a prerequisite to perform surgeries for temporal lobe epilepsy. We used in vivo morphometry to identify the standard direction for entry into the inferior horn of the lateral ventricle via the Sylvian fissure: an important initial step in performing transsylvian selective amygdalohippocampectomy. 3D magnetic resonance images obtained from 28 patients without intra-parenchymal lesions were re-oriented to demonstrate all points in the Talairach space of the brain. The limen insulae and the midpoint between the hippocampal sulcus and the innominate sulcus on the coronal slice through the posterior edge of the amygdala were defined as the start and target points, respectively. We evaluated the direction of the vector between these two points and its validity in the brain of 12 patients with temporal lobe epilepsy. The direction of the mean approach vector was 52.4° posteriorly and 16.2° inferiorly. The mean approach vector on the axial plane showed the approximate parallelism with the sphenoid ridge in individual cases. The computer simulation revealed that our average approach vector correctly entered the inferior horn of the lateral ventricle in all temporal lobe epilepsy brains. In vivo morphometry may contribute to the further development of safe and minimally-invasive neurosurgical procedures.
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Affiliation(s)
- Tadashi Hamasaki
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Toshinori Hirai
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan ; Department of Diagnostic Radiology, Kumamoto University Medical School, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan ; Department of Radiology, Faculty of Medicine, University of Miyazaki, 5200 Kiyotake, Miyazaki, 889-1692 Japan
| | - Kazumichi Yamada
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
| | - Jun-Ichi Kuratsu
- Department of Neurosurgery, Kumamoto University Medical School, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 Japan
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Lin CH, Chen CM, Lu MK, Tsai CH, Chiou JC, Liao JR, Duann JR. VBM Reveals Brain Volume Differences between Parkinson's Disease and Essential Tremor Patients. Front Hum Neurosci 2013; 7:247. [PMID: 23785322 PMCID: PMC3682128 DOI: 10.3389/fnhum.2013.00247] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 05/19/2013] [Indexed: 01/18/2023] Open
Abstract
Symptoms of essential tremor (ET) are similar to those of Parkinson’s disease (PD) during their initial stages. Presently, there are few stable biomarkers available on a neuroanatomical level for distinguishing between these two diseases. However, few investigations have directly compared the changes in brain volume and assessed the compensatory effects of a change in the parts of the brain associated with PD and with ET. To determine the compensatory and/or degenerative anatomical changes in the brains of PD and ET patients, the present study tested, via two voxel-based morphometry (VBM) approaches (Basic vs. DARTEL VBM processing), the anatomical brain images of 10 PD and 10 ET patients, as well as of 13 age-matched normal controls, obtained through a 3T magnetic resonance scanner. These findings indicate that PD and ET caused specific patterns of brain volume alterations in the brains examined. In addition, our observations also revealed compensatory effects, or self-reorganization, occurring in the thalamus and the middle temporal gyrus in the PD and ET patients, due perhaps in part to the enhanced thalamocortical sensorimotor interaction and the head-eye position readjustment, respectively, in these PD and ET patients. Such a distinction may lend itself to use as a biomarker for differentiating between these two diseases.
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Affiliation(s)
- Ching-Hung Lin
- Biomedical Engineering R&D Center, China Medical University , Taichung , Taiwan ; Biomedical Electronics Translational Research Center, National Chiao Tung University , Hsinchu , Taiwan ; Department of Psychology, Soochow University , Taipei , Taiwan
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Hamasaki T, Imamura JI, Kai Y, Ohmori Y, Kuratsu JI. Accurate estimation of motor symptoms by diffusion tensor imaging in a patient with advanced Moyamoya disease. Clin Neurol Neurosurg 2012; 114:1042-5. [PMID: 22366243 DOI: 10.1016/j.clineuro.2012.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Revised: 01/04/2012] [Accepted: 01/28/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Tadashi Hamasaki
- Laboratory of Neuroimaging, Department of Neurosurgery, National Hospital Organization Kagoshima Medical Center, 8-1 Shiroyama-cho, Kagoshima 899-0853, Japan.
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Hamasaki T, Imamura JI, Kawai H, Kuratsu JI. A three-dimensional MRI study of variations in central sulcus location in 40 normal subjects. J Clin Neurosci 2012; 19:115-20. [DOI: 10.1016/j.jocn.2011.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 06/09/2011] [Accepted: 06/11/2011] [Indexed: 10/14/2022]
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