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Duraffourg M, Rougereau G, Fawaz R, Ltaief A, Jacquesson T, Freydier M, Baude C, Robert R, Mertens P. Lumbosacral plexus and pudendal nerve magnetic resonance tractography: A systematic review of the clinical applications for pudendal neuralgia. Magn Reson Imaging 2024; 112:18-26. [PMID: 38797289 DOI: 10.1016/j.mri.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/18/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
Diffusion tensor imaging (DTI) is commonly used to establish three-dimensional mapping of white-matter bundles in the supraspinal central nervous system. DTI has also been the subject of many studies on cranial and peripheral nerves. This non-invasive imaging technique enables virtual dissection of nerves in vivo and provides specific measurements of microstructural integrity. Adverse effects on the lumbosacral plexus may be traumatic, compressive, tumoral, or malformative and thus require dedicated treatment. DTI could lead to new perspectives in pudendal neuralgia diagnosis and management. We performed a systematic review of all articles or posters reporting results and protocols for lumbosacral plexus mapping using the DTI technique between January 2011 and December 2023. Twenty-nine articles published were included. Ten studies with a total of 351 participants were able to track the lumbosacral plexus in a physiological context and 19 studies with a total of 402 subjects tracked lumbosacral plexus in a pathological context. Tractography was performed on a 1.5T or 3T MRI system. DTI applied to the lumbosacral plexus and pudendal nerve is feasible but no microstructural normative value has been proposed for the pudendal nerve. The most frequently tracking parameters used in our review are: 3T MRI, b-value of 800 s/mm2, 33 directions, 3 × 3 × 3 mm3, AF threshold of 0.1, minimum fiber length of 10 mm, bending angle of 30°, and 3DT2 TSE anatomical resolution. Increased use of DTI could lead to new perspectives in the management of pudendal neuralgia due to entrapment syndrome, whether at the diagnostic, prognostic, or preoperative planning level. Prospective studies of healthy subjects and patients with the optimal acquisition parameters described above are needed to establish the accuracy of MR tractography for diagnosing pudendal neuralgia and other intrapelvic nerve entrapments.
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Affiliation(s)
- M Duraffourg
- Unité de Neuromodulation Polyvalente, Service de Neurochirurgie fonctionnelle de la moelle et des nerfs périphériques - Hospices Civils de Lyon, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Centre d'Évaluation et de Traitement de la Douleur, Hospices Civils de Lyon- Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France
| | - G Rougereau
- Service de chirurgie orthopédique et traumatologique Hôpital Pitié Salpetrière, Paris, France
| | - R Fawaz
- Unité de Neuromodulation Polyvalente, Service de Neurochirurgie fonctionnelle de la moelle et des nerfs périphériques - Hospices Civils de Lyon, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Centre d'Évaluation et de Traitement de la Douleur, Hospices Civils de Lyon- Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Service de Neurochirurgie - Hôpital d'Instruction des Armées Percy, Clamart, France.
| | - A Ltaief
- Service d'imagerie médicale et interventionnelle - Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - T Jacquesson
- Service de Neurochirurgie crânienne générale, tumorale et vasculaire - Hospices Civils de Lyon- Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon, France
| | - M Freydier
- Centre d'Évaluation et de Traitement de la Douleur - Centre Hospitalier de Macon, Macon, France; Centre d'Évaluation et de Traitement de la Douleur - Médipôle Hôpital Mutualiste, Villeurbanne, France
| | - C Baude
- Centre d'Évaluation et de Traitement de la Douleur - Médipôle Hôpital Mutualiste, Villeurbanne, France
| | - R Robert
- Service de chirurgie - Hôpital Privé du Confluent, Nantes, France; Faculté de Médecine de Nantes, Nantes, France
| | - P Mertens
- Unité de Neuromodulation Polyvalente, Service de Neurochirurgie fonctionnelle de la moelle et des nerfs périphériques - Hospices Civils de Lyon, Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Centre d'Évaluation et de Traitement de la Douleur, Hospices Civils de Lyon- Hôpital neurologique et neurochirurgical Pierre Wertheimer, Bron, France; Faculté de Médecine Lyon Est, Université Claude Bernard, Lyon, France
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Dong D, Hosomi K, Mori N, Kamijo YI, Furotani Y, Yamagami D, Ohnishi YI, Watanabe Y, Nakamura T, Tajima F, Kishima H, Saitoh Y. White matter microstructural alterations in patients with neuropathic pain after spinal cord injury: a diffusion tensor imaging study. Front Neurol 2023; 14:1241658. [PMID: 37693753 PMCID: PMC10484711 DOI: 10.3389/fneur.2023.1241658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Background Through contrastive analysis, we aimed to identify the white matter brain regions that show microstructural changes in patients with neuropathic pain (NP) after spinal cord injury (SCI). Methods We categorized patients with SCI into NP (n = 30) and non-NP (n = 15) groups. We extracted diffusion tensor maps of fractional anisotropy (FA) and mean (MD), axial (AD), and radial (RD) diffusivity. A randomization-based method in tract-based spatial statistics was used to perform voxel-wise group comparisons among the FA, MD, AD, and RD for nonparametric permutation tests. Results Atlas-based analysis located significantly different regions (p < 0.05) in the appointed brain atlas. Compared to the non-NP group, the NP group showed higher FA in the posterior body and splenium of the corpus callosum and higher AD in the corpus callosum, internal capsule, corona radiata, posterior thalamic radiation, sagittal stratum, external capsule, cingulum, fornix/stria terminalis, superior longitudinal fasciculus, and uncinate fasciculus. Conclusion The results demonstrated that compared with the non-NP group, NP pathogenesis after SCI was potentially related to higher values in FA that are associated with microstructural changes in the posterior body and splenium of the corpus callosum, which could be regarded as central sensitization or network hyperexcitability.
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Affiliation(s)
- Dong Dong
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Toyonaka, Osaka, Japan
| | - Koichi Hosomi
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Nobuhiko Mori
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshi-ichiro Kamijo
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
- Department of Rehabilitation Medicine, Saitama Medical Center, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Yohei Furotani
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Daisuke Yamagami
- Department of Rehabilitation Medicine, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
- Department of Rehabilitation Medicine, Kanagawa Rehabilitation Hospital, Atsugi, Kanagawa, Japan
| | - Yu-ichiro Ohnishi
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
- Department of Neurosurgery, Osaka Gyoumeikan Hospital, Osaka, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takeshi Nakamura
- Department of Rehabilitation Medicine, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Youichi Saitoh
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Toyonaka, Osaka, Japan
- Tokuyukai Rehabilitation Clinic, Toyonaka, Osaka, Japan
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Corroenne R, Grevent D, Mahallati H, Gauchard G, Bussieres L, Ville Y, Salomon LJ. Diffusion tensor imaging of fetal spinal cord: feasibility and gestational-age-related changes. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:241-247. [PMID: 36971038 DOI: 10.1002/uog.26208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Diffusion tensor imaging (DTI) of the fetal brain is a relatively new technique that allows evaluation of white matter tracts of the central nervous system throughout pregnancy, as well as in certain pathological conditions. The objectives of this study were to evaluate the feasibility of DTI of the spinal cord in utero and to examine gestational-age (GA)-related changes in DTI parameters during pregnancy. METHODS This was a prospective study conducted between December 2021 and June 2022 in the LUMIERE Platform, Necker-Enfants Malades Hospital, Paris, France, as part of the LUMIERE SUR LE FETUS trial. Women with a pregnancy between 18 and 36 weeks of gestation without fetal or maternal abnormality were eligible for inclusion. Sagittal diffusion-weighted scans of the fetal spine were acquired, without sedation, using a 1.5-Tesla magnetic resonance imaging scanner. The imaging parameters were as follows: 15 non-collinear direction diffusion-weighted magnetic-pulsed gradients with a b-value 700 s/mm2 and one B0 image without diffusion-weighting; slice thickness, 3 mm; field of view (FOV), 36 mm; phase FOV, 1.00; voxel size, 4.5 × 2.8 × 3 mm3 ; number of slices, 7-10; repetition time, 2800 ms; echo time, minimum; and total acquisition time, 2.3 min. DTI parameters, including fractional anisotropy (FA) and apparent diffusion coefficient (ADC), were extracted at the cervical, upper thoracic, lower thoracic and lumbar levels of the spinal cord. Cases with motion degradation and those with aberrant reconstruction of the spinal cord on tractography were excluded. Pearson's correlation analysis was performed to evaluate GA-related changes of DTI parameters during pregnancy. RESULTS During the study period, 42 pregnant women were included at a median GA of 29.3 (range, 22.0-35.7) weeks. Five (11.9%) patients were not included in the analysis because of fetal movement. Two (4.8%) patients with aberrant tractography reconstruction were also excluded from analysis. Acquisition of DTI parameters was feasible in all remaining cases (35/35). Increasing GA correlated with increasing FA averaged over the entire fetal spinal cord (r, 0.37; P < 0.01), as well as at the individual cervical (r, 0.519; P < 0.01), upper thoracic (r, 0.468; P < 0.01), lower thoracic (r, 0.425; P = 0.02) and lumbar (r, 0.427; P = 0.02) levels. There was no correlation between GA and ADC averaged over the entire spinal cord (r, 0.01; P = 0.99) or at the individual cervical (r, -0.109; P = 0.56), upper thoracic (r, -0.226; P = 0.22), lower thoracic (r, -0.052; P = 0.78) or lumbar (r, -0.11; P = 0.95) levels. CONCLUSIONS This study shows that DTI of the spinal cord is feasible in normal fetuses in typical clinical practice and allows extraction of DTI parameters of the spinal cord. There is a significant GA-related change in FA in the fetal spinal cord during pregnancy, which may result from decreasing water content as observed during myelination of fiber tracts occurring in utero. This study may serve as a basis for further investigation of DTI in the fetus, including research into its potential in pathological conditions that impact spinal cord development. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Corroenne
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - D Grevent
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
- Department of Radiology, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - H Mahallati
- Department of Radiology, University of Calgary, Alberta, Canada
| | - G Gauchard
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
| | - L Bussieres
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Y Ville
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - L J Salomon
- EA Fetus 7328 and LUMIERE Platform, University of Paris, Paris, France
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, AP-HP, Paris, France
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van der Kruk E, Strutton P, Koizia LJ, Fertleman M, Reilly P, Bull AMJ. Why do older adults stand-up differently to young adults?: investigation of compensatory movement strategies in sit-to-walk. NPJ AGING 2022; 8:13. [PMID: 36064553 PMCID: PMC9445096 DOI: 10.1038/s41514-022-00094-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
AbstractFunctional motor redundancy enables humans to move with distinct muscle activation patterns while achieving a similar outcome. Since humans select similar strategies, there seems to be an optimal control. However, older adults move differently to young adults. The question is whether this is this due to an altered reinforcement scheme, altered sensory inputs, or due to alterations in the neuromusculoskeletal systems, so that it is no longer optimal or possible to execute the same movement strategies. The aim of this study was to analyse natural compensation strategies in the vital daily-life-task, sit-to-walk, in relation to neuromuscular capacity and movement objectives in younger (27.2 ± 4.6 years, N = 27, 14♀) and elderly (75.9 ± 6.3 years, N = 23, 12♀) adults. Aspects of the neuromuscular system that are prone to age-related decline and feasible to quantify were assessed (i.e. strength, nerve conductivity, fear of falling). Kinematics and muscle activity were recorded and joint kinetics were estimated using biomechanical models. Elderly men consistently used their arms when standing up. This strategy was not associated with a lack of or a reduction in strength, but with a reduction, but no lack of, ankle joint range of motion, and with increased fear of falling. The results show that humans preferentially maintain a minimum threshold of neuromuscular reserve to cope with uncertainties which results in compensation prior to coming up against physical limitations. Smaller base of support while standing up, a compensatory strategy with possibly greater risk of falls, was associated with muscular weakness, and longer nerve conduction latencies.
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Liang S, Yang F, Zhang Y, Zhao H, Wang X. Changes and clinical correlation of diffusion tensor imaging parameters of compressed spinal cord and nerve root in patients with cervical spondylosis. BMC Med Imaging 2022; 22:107. [PMID: 35659198 PMCID: PMC9166510 DOI: 10.1186/s12880-022-00835-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diffusion tensor imaging (DTI) was used to quantitatively study the characteristics of the related spinal cord and nerve root compression parameters in patients with cervical spondylosis (CS), and diffusion tensor tractography (DTT) was used to visualize the spinal cord and nerve root and analyze their relevance to clinical evaluation. METHODS A total of 67 patients with CS and 30 healthy volunteers received 3.0 T magnetic resonance imaging. Cervical DTI and DTT were performed in all the participants, where the b value of DTI was set at 800 s/mm2. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of the spinal cord and cervical nerve roots were measured by using DTI. Patients with CS were scored according to the modified Japanese Orthopedic Association (mJOA) score. RESULTS In all the participants, the spinal cord and cervical nerve roots were clearly visible by DTT. Compared to the healthy volunteers, the FA values were significantly decreased and ADC values were significantly increased in patients with CS. mJOA score was significantly correlated with the DTI index (ADC and FA) values. Receiver operator characteristic curve analysis revealed that FA and ADC could identify mild, moderate, and severe CS. CONCLUSIONS DTI parameters of cervical spinal cord and nerve root compression are associated with the clinical evaluation of patients with CS and may be helpful in assessing the severity of CS.
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Affiliation(s)
- Shuo Liang
- Department of Radiology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning, China
| | - Feng Yang
- Department of Radiology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning, China.
| | - Yang Zhang
- Department of Spine Surgery, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning, China.
| | - Huiyu Zhao
- Department of Radiology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning, China
| | - Xinyue Wang
- Department of Radiology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning, China
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Hodel J, Lefaucheur JP, Tolédano S, Badat N, Rondenet C, Zuber M, Zins M, Créange A. Diffusion tensor imaging MR neurography in patients with acute or chronic plexopathy. J Neuroradiol 2021; 49:2-8. [PMID: 34171314 DOI: 10.1016/j.neurad.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/04/2021] [Accepted: 06/15/2021] [Indexed: 01/28/2023]
Abstract
The nerve plexus is susceptible to various pathological processes. In addition to clinical and electrophysiological findings, magnetic resonance neurography (MRN) may contribute to characterize plexus involvement. Diffusion tensor imaging (DTI) was reported feasible for the nerve plexuses imaging but its value in the clinical practice remains uncertain. From 2014 to 2020, we routinely performed MRN including DTI at 3T in patients with acute or chronic plexopathy. DTI images were co-registered with conventional MRN images. MRN images including DTI were reviewed by consensus by two neuroradiologists and one neurologist. They retrospectively identified cases for whom the use of DTI had a potential impact on the diagnostic workup, seven of these clinical cases are presented here. Compared to conventional MRN, the added value of DTI consisted in: (i) improved detection of signal/morphological abnormalities of the plexus (due to removal of background structures, multiplanar reformatted views and large field of view), (ii) additional information regarding the microarchitecture of nerve fibers provided by DTI metrics, (iii) potential alternative for the use of gadolinium. This case series supports the implementation of DTI in MRN protocols.
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Affiliation(s)
- Jérôme Hodel
- Department of Radiology, Saint Joseph Hospital, Paris, France.
| | - Jean-Pascal Lefaucheur
- Department of Physiology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, EA 4391, France; Nerve Excitability and Therapeutic Team (ENT), Faculty of Medicine, Paris Est Créteil University, Créteil, France
| | - Sarah Tolédano
- Department of Radiology, Saint Joseph Hospital, Paris, France
| | - Neesmah Badat
- Department of Radiology, Saint Joseph Hospital, Paris, France
| | | | - Mathieu Zuber
- Department of Neurology, Saint Joseph Hospital, Paris, France; INSERM UMR S919, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Marc Zins
- Department of Radiology, Saint Joseph Hospital, Paris, France
| | - Alain Créange
- Department of Neurology, Henri Mondor Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France
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Hughes SW, Hellyer PJ, Sharp DJ, Newbould RD, Patel MC, Strutton PH. Diffusion tensor imaging of lumbar spinal nerves reveals changes in microstructural integrity following decompression surgery associated with improvements in clinical symptoms: A case report. Magn Reson Imaging 2020; 69:65-70. [PMID: 32084517 DOI: 10.1016/j.mri.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/07/2020] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
The outcomes from spinal nerve decompression surgery are highly variable with a sizable proportion of elderly foraminal stenosis patients not regaining good pain relief. A better understanding of nerve root compression before and following decompression surgery and whether these changes are mirrored by improvements in symptoms may help to improve clinical decision-making processes. This case study used a combination of diffusion tensor imaging (DTI), clinical questionnaires and motor neurophysiology assessments before and up to 3 months following spinal decompression surgery. In this case report, a 70-year-old women with compression of the left L5 spinal nerve root in the L5-S1 exit foramina was recruited to the study. At 3 months following surgery, DTI revealed marked improvements in left L5 microstructural integrity to a similar level to that seen in the intact right L5 nerve root. This was accompanied by a gradual improvement in pain-related symptoms, mood and disability score by 3 months. Using this novel multimodal approach, it may be possible to track concurrent improvements in pain-related symptoms, function and microstructural integrity of compressed nerves in elderly foraminal stenosis patients undergoing decompression surgery.
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Affiliation(s)
- Sam W Hughes
- The Nick Davey Laboratory, Division of Surgery, Imperial College London, UK.
| | - Peter J Hellyer
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, London, UK; Department of Bioengineering, Imperial College London, UK
| | - David J Sharp
- Computational, Cognitive and Clinical Neuroimaging Laboratory, Division of Brain Sciences, Imperial College London, London, UK
| | | | - Maneesh C Patel
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Paul H Strutton
- The Nick Davey Laboratory, Division of Surgery, Imperial College London, UK
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Fritz J, Ahlawat S. Getting Quantitative Diffusion-Weighted MR Neurography and Tractography Ready for Clinical Practice. J Magn Reson Imaging 2019; 51:1138-1139. [PMID: 31507015 DOI: 10.1002/jmri.26930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jan Fritz
- From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shivani Ahlawat
- From the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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