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Squintani G, Basaldella F, Badari A, Rasera A, Tramontano V, Pinna G, Moscolo F, Soda C, Ricci U, Ravenna G, Sala F. Intraoperative Neurophysiological Monitoring in Tethered Cord Syndrome Surgery: Predictive Values and Clinical Outcome. J Clin Neurophysiol 2024:00004691-990000000-00138. [PMID: 38905022 DOI: 10.1097/wnp.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION "Tethered cord syndrome" (TCS) refers to a congenital abnormality associated with neurological signs and symptoms. The aim of surgery is to prevent or arrest their progression. This study reports a retrospective case series of tethered cord syndrome surgeries, supported by intraoperative neurophysiological monitoring. METHODS The case series comprises 50 surgeries for tethered cord syndrome in which multimodal intraoperative neurophysiological monitoring was performed using motor evoked potentials (transcranial motor evoked potentials [TcMEPs]), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal-anal reflex (PAR). The intraoperative neurophysiological monitoring results are reported and correlated with clinical outcomes. RESULTS Sensitivity, specificity, and negative predictive value were high for TcMEPs and TNSEPs, while PAR exhibited low sensitivity and positive predictive value but high specificity and negative predictive value. Fisher's exact test revealed a significant correlation between changes in TcMEPs, TNSEPs, and clinical outcome ( P < 0.000 and P = 0.049 respectively), but no correlation was detected between PAR and urinary/anal function ( P = 0.497). CONCLUSIONS While TcMEPs and TNSEPs were found to be reliable intraoperative neurophysiological monitoring parameters during tethered cord syndrome surgery, PAR had low sensitivity and positive predictive value probably because the reflex is not directly related to bladder function and because its multisynaptic pathway may be sensitive to anesthetics. New onset muscle weakness and sensory deficits were related to postoperative changes in TcMEPs and TNSEPs, whereas changes in PAR did not predict bladder/urinary impairment. Urinary deficits may be predicted and prevented with other neurophysiological techniques, such as the bladder-anal reflex.
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Affiliation(s)
- Giovanna Squintani
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Andrea Badari
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Andrea Rasera
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- Neurology Unit, Ospedale Ca' Foncello, Treviso, Italy
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Vincenzo Tramontano
- Neurology and Neurophysiology Unit, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Giampietro Pinna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Fabio Moscolo
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Soda
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Umberto Ricci
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Giorgio Ravenna
- Neurosurgery Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; and
| | - Francesco Sala
- Neurosurgery Unit, Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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Avesani G, Perazzolo A, Elia L, Anghelone AG, Gaudino S, Russo L, Genco E, Di Paola V, Massimi L, De Santis M, Tamburrini G, Manfredi R. Fetal MRI prior to intrauterine surgery of open neural tube defects: What does the radiologist need to know. LA RADIOLOGIA MEDICA 2023; 128:113-124. [PMID: 36525177 DOI: 10.1007/s11547-022-01579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
The management of myelomeningocele study trial showed significant prognostic improvement in fetal repair before 26 weeks of gestation. Hence, surgery in utero represents the best treatment option for open-neural tube defects (NTDs). Fetal surgery of open-NTDs has specific inclusion and exclusion criteria, which can be adequately studied with fetal MRI. The main concern: the spine (spinal defects other than Myelomeningocele and Myeloschisis, the level of the lesion higher than T1 or lower than S1 and the degree of kyphosis ≥ 30°), the skull/brain (no cerebellum herniation and Chiari II malformation and the presence of any intracranial abnormality unrelated to open NTDs), the uterus (cervix length less than 2 cm, multiple gestations and placental and uterine abnormalities) and any other fetal abnormality not attributed to spinal defect. In this review, we describe the fundamental role of fetal MRI in supporting therapeutic decisions in pre-surgery intrauterine planning through the accurate and comprehensive description of findings, providing a proposal of a structured report. In addition, we describe how post-surgical MRI is important in investigating the effectiveness of surgery and detecting repairing complications.
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Affiliation(s)
- Giacomo Avesani
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | | - Lorenzo Elia
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Simona Gaudino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Russo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Enza Genco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Valerio Di Paola
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Massimi
- Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Marco De Santis
- Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Gianpiero Tamburrini
- Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Riccardo Manfredi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Scalia G, Marrone S, Costanzo R, Umana GE, Riolo C, Graziano F, Ponzo G, Giuffrida M, Furnari M, Florio A, Iacopino DG, Nicoletti GF. Dural splitting reconstruction in retethering after lipomeningocele repair: Technical note. Surg Neurol Int 2021; 12:422. [PMID: 34513186 PMCID: PMC8422439 DOI: 10.25259/sni_734_2021] [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: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Tethered spinal cord syndrome (TCS) can occur after the surgical repair of lipomeningoceles (LMCs). In these cases, the tethering results from postoperative adhesions between the spinal cord and the overlying repaired dura. A watertight dural closure using the residual dura and/or the surrounding tissues does not always provide enough space for the spinal cord and risks retethering. Here, we report a 16-year-old patient with secondary TCS following lipomeningocele repair who successfully underwent release of the tethered filum terminale utilizing a novel dural splitting reconstructive technique to attain a water-tight closure without the need for a duroplasty. Methods: A 16-year-old patient had a LMC repaired at birth. She now presented with progressive low back pain, and gait disturbances. The MRI documented secondary spinal cord tethering at the prior spinal dysraphism repair site. Results: A secondary release of the filum terminale utilizing a novel dural splitting technique to avoid the need for a duroplasty was performed. Conclusion: Here, in a 16-year-old patient with a recurrent tethered cord syndrome following repair of a LMC at birth, we utilized a novel dural splitting reconstruction technique and averted the need for a duroplasty.
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Affiliation(s)
- Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Salvatore Marrone
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Catania, Sicily, Italy
| | - Roberta Costanzo
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Catania, Sicily, Italy
| | | | - Carmelo Riolo
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Francesca Graziano
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Giancarlo Ponzo
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Massimiliano Giuffrida
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Massimo Furnari
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Agatino Florio
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, AOUP "Paolo Giaccone," Palermo, Catania, Sicily, Italy
| | - Giovanni Federico Nicoletti
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi," Catania, Sicily, Italy
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Trapp B, de Andrade Lourenção Freddi T, de Oliveira Morais Hans M, Fonseca Teixeira Lemos Calixto I, Fujino E, Alves Rojas LC, Burlin S, Cerqueira Costa DM, Carrete Junior H, Abdala N, Tobaru Tibana LA, Takehara ET, Dalul Gomez G. A Practical Approach to Diagnosis of Spinal Dysraphism. Radiographics 2021; 41:559-575. [PMID: 33449837 DOI: 10.1148/rg.2021200103] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Spinal dysraphisms (SDs) are congenital malformations of the spinal cord, determined by derangement in the complex cascade of embryologic events involved in spinal development. They represent a heterogeneous group ranging from mild clinical manifestations-going unnoticed or being discovered at clinical examination-to a causal factor of life quality impairment, especially when associated with musculoskeletal, gastrointestinal, genitourinary, or respiratory system malformations. Knowledge of the normal embryologic development of the spinal cord-which encompasses three main steps (gastrulation, primary neurulation, and secondary neurulation)-is crucial for understanding the pathogenesis, neuroradiologic scenarios, and clinical-radiologic classification of congenital malformations of the spinal cord. SDs can be divided with clinical examination or neuroradiologic study into two major groups: open SDs and closed SDs. Congenital malformations of the spinal cord include a wide range of abnormalities that vary considerably in imaging and clinical characteristics and complexity and therefore may represent a diagnostic challenge, even for the experienced radiologist. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Bárbara Trapp
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Tomás de Andrade Lourenção Freddi
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Monique de Oliveira Morais Hans
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Isadora Fonseca Teixeira Lemos Calixto
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Emi Fujino
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Laila Cristina Alves Rojas
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Stênio Burlin
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Danilo Manuel Cerqueira Costa
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Henrique Carrete Junior
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Nitamar Abdala
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Luís Antônio Tobaru Tibana
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Eduardo Takashi Takehara
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
| | - Gustavo Dalul Gomez
- From the Department of Diagnostic Imaging, Division of Neuroradiology, Universidade Federal de São Paulo (UNIFESP), Rua Napoleão de Barros 800, São Paulo SP 04024-002, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., E.F., L.C.A.R., S.B., D.M.C.C., H.C.J., N.A., L.A.T.T., E.T.T., G.D.G.); Department of Diagnostic Imaging, Division of Neuroradiology, Hospital do Coração (HCor), São Paulo, Brazil (T.d.A.L.F.); and Department of Diagnostic Imaging, Division of Neuroradiology, Fundação Instituto de Pesquisa e Estudo de Diagnóstico por Imagem (FIDI), São Paulo, Brazil (B.T., M.d.O.M.H., I.F.T.L.C., L.C.A.R., S.B., L.A.T.T.)
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