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He Z, Tang T, Zhu Z, Wang F, Li J, Zhang F, Tung NTC, Liu S, Liu X, Zhou Z. Development of a mouse model of chronic ventral spinal cord compression: Neurobehavioral, radiological, and pathological changes. JOR Spine 2024; 7:e1350. [PMID: 38993525 PMCID: PMC11237184 DOI: 10.1002/jsp2.1350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/13/2024] Open
Abstract
Objectives The main objective of this study was to establish a mouse model of spinal ligament ossification to simulate the chronic spinal cord compression observed in patients with ossification of the posterior longitudinal ligament (OPLL). The study also aimed to examine the mice's neurobiological, radiological, and pathological changes. Methods In the previous study, a genetically modified mouse strain was created using Crispr-Cas9 technology, namely, Enpp1 flox/flox /EIIa-Cre (C57/B6 background), to establish the OPLL model. Wild-type (WT) mice without compression were used as controls. Functional deficits were evaluated through motor score assessment, inclined plate testing, and gait analysis. The extent of compression was determined using CT imaging. Hematoxylin and eosin staining, luxol fast blue staining, TUNEL assay, immunofluorescence staining, qPCR, and Western blotting were performed to evaluate levels of apoptosis, inflammation, vascularization, and demyelination in the study. Results The results demonstrated a gradual deterioration of compression in the Enpp1 flox/flox /EIIa-Cre mice group as they aged. The progression rate was more rapid between 12 and 20 weeks, followed by a gradual stabilization between 20 and 28 weeks. The scores for spinal cord function and strength, assessed using the Basso Mouse Scale and inclined plate test, showed a significant decline. Gait analysis revealed a noticeable reduction in fore and hind stride lengths, stride width, and toe spread. Chronic spinal cord compression resulted in neuronal damage and activated astrocytes and microglia in the gray matter and anterior horn. Progressive posterior cervical compression impeded blood supply, leading to inflammation and Fas-mediated neuronal apoptosis. The activation of Bcl2 and Caspase 3 was associated with the development of progressive neurological deficits (p < 0.05). Conclusions The study presents a validated model of chronic spinal cord compression, enabling researchers to explore clinically relevant therapeutic approaches for OPLL.
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Affiliation(s)
- Zhongyuan He
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
- Department of OrthopedicsThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Tao Tang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
- Department of OrthopedicsThe Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Zhengya Zhu
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
- Department of OrthopedicsAffiliated Hospital of Xuzhou Medical UniversityXuzhouChina
| | - Fuan Wang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
| | - Jianfeng Li
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
| | - Fu Zhang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
| | - Nguyen Tran Canh Tung
- Department of Orthopedic Surgery, Faculty of MedicineUniversity of ToyamaToyamaJapan
| | - Shaoyu Liu
- Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xizhe Liu
- Guangdong Provincial Key Laboratory of Orthopedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Zhiyu Zhou
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopedic SurgeryThe Seventh Affiliated Hospital of Sun Yat‐sen UniversityShenzhenChina
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Valošek J, Cohen-Adad J. Reproducible Spinal Cord Quantitative MRI Analysis with the Spinal Cord Toolbox. Magn Reson Med Sci 2024; 23:307-315. [PMID: 38479843 PMCID: PMC11234946 DOI: 10.2463/mrms.rev.2023-0159] [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] [Indexed: 07/02/2024] Open
Abstract
The spinal cord plays a pivotal role in the central nervous system, providing communication between the brain and the body and containing critical motor and sensory networks. Recent advancements in spinal cord MRI data acquisition and image analysis have shown a potential to improve the diagnostics, prognosis, and management of a variety of pathological conditions. In this review, we first discuss the significance of standardized spinal cord MRI acquisition protocol in multi-center and multi-manufacturer studies. Then, we cover open-access spinal cord MRI datasets, which are important for reproducible science and validation of new methods. Finally, we elaborate on the recent advances in spinal cord MRI data analysis techniques implemented in the open-source software package Spinal Cord Toolbox (SCT).
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Affiliation(s)
- Jan Valošek
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, QC, Canada
- Mila - Quebec AI Institute, Montreal, QC, Canada
- Department of Neurosurgery, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, QC, Canada
- Mila - Quebec AI Institute, Montreal, QC, Canada
- Functional Neuroimaging Unit, CRIUGM, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
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Horak T, Horakova M, Kerkovsky M, Dostal M, Hlustik P, Valosek J, Svatkova A, Bednarik P, Vlckova E, Bednarik J. Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy. Front Neurol 2024; 15:1341371. [PMID: 38798708 PMCID: PMC11116587 DOI: 10.3389/fneur.2024.1341371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/18/2024] [Indexed: 05/29/2024] Open
Abstract
Degenerative cervical myelopathy (DCM) represents the final consequence of a series of degenerative changes in the cervical spine, resulting in cervical spinal canal stenosis and mechanical stress on the cervical spinal cord. This process leads to subsequent pathophysiological processes in the spinal cord tissues. The primary mechanism of injury is degenerative compression of the cervical spinal cord, detectable by magnetic resonance imaging (MRI), serving as a hallmark for diagnosing DCM. However, the relative resilience of the cervical spinal cord to mechanical compression leads to clinical-radiological discordance, i.e., some individuals may exhibit MRI findings of DCC without the clinical signs and symptoms of myelopathy. This degenerative compression of the cervical spinal cord without clinical signs of myelopathy, potentially serving as a precursor to the development of DCM, remains a somewhat controversial topic. In this review article, we elaborate on and provide commentary on the terminology, epidemiology, natural course, diagnosis, predictive value, risks, and practical management of this condition-all of which are subjects of ongoing debate.
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Affiliation(s)
- Tomas Horak
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Magda Horakova
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Milos Kerkovsky
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
| | - Marek Dostal
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
- Department of Biophysics, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Hlustik
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- Department of Neurology, University Hospital Olomouc, Olomouc, Czechia
| | - Jan Valosek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- Department of Neurosurgery, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, QC, Canada
- Mila—Quebec AI Institute, Montreal, QC, Canada
| | - Alena Svatkova
- Danish Research Center for Magnetic Resonance, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Petr Bednarik
- Danish Research Center for Magnetic Resonance, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Eva Vlckova
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Josef Bednarik
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
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Khan AF, Mohammadi E, Haynes G, Hameed S, Rohan M, Anderson DB, Weber KA, Muhammad F, Smith ZA. Evaluating tissue injury in cervical spondylotic myelopathy with spinal cord MRI: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:133-154. [PMID: 37926719 DOI: 10.1007/s00586-023-07990-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/02/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE Cervical Spondylotic Myelopathy (CSM) is a degenerative condition that leads to loss of cervical spinal cord (CSC) integrity. Various spinal cord Magnetic Resonance Imaging (MRI) methods can identify and characterize the extent of this damage. This systematic review aimed to evaluate the diagnostic, biomarker, and predictive utilities of different spinal cord MRI methods in clinical research studies of CSM. The aim was to provide a comprehensive understanding of the progress in this direction for future studies and effective diagnosis and management of CSM. METHODS A comprehensive literature search was conducted on PubMed and EMBASE from 2010 to 2022 according to PRISMA guidelines. Studies with non-human subjects, less than 3T magnetic field strength, non-clinical design, or not quantitatively focusing on the structural integrity of CSC were excluded. The extracted data from each study included demographics, disease severity, MRI machine characteristics, quantitative metrics, and key findings in terms of diagnostic, biomarker, and predictive utilities of each MRI method. The risk of bias was performed using the guide from AHRQ. The quality of evidence was assessed separately for each type of utility for different MRI methods using GRADE. RESULTS Forty-seven studies met the inclusion criteria, utilizing diffusion-weighted imaging (DTI) (n = 39), magnetization transfer (MT) (n = 6), MR spectroscopy (n = 3), and myelin water imaging (n = 1), as well as a combination of MRI methods (n = 12). The metric fractional anisotropy (FA) showed the highest potential in all facets of utilities, followed by mean diffusivity. Other promising metrics included MT ratio and intracellular volume fraction, especially in multimodal studies. However, the level of evidence for these promising metrics was low due to a small number of studies. Some studies, mainly DTI, also reported the usefulness of spinal cord MRI in mild CSM. CONCLUSIONS Spinal cord MRI methods can potentially facilitate the diagnosis and management of CSM by quantitatively interrogating the structural integrity of CSC. DTI is the most promising MRI method, and other techniques have also shown promise, especially in multimodal configurations. However, this field is in its early stages, and more studies are needed to establish the usefulness of spinal cord MRI in CSM.
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Affiliation(s)
- Ali Fahim Khan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Esmaeil Mohammadi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Grace Haynes
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, USA
| | - Sanaa Hameed
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Michael Rohan
- Laureate Institute for Brain Research, Tulsa, OK, USA
| | - David B Anderson
- School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Kenneth A Weber
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Fauziyya Muhammad
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA.
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Khan AF, Haynes G, Mohammadi E, Muhammad F, Hameed S, Smith ZA. Utility of MRI in Quantifying Tissue Injury in Cervical Spondylotic Myelopathy. J Clin Med 2023; 12:jcm12093337. [PMID: 37176777 PMCID: PMC10179707 DOI: 10.3390/jcm12093337] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Cervical spondylotic myelopathy (CSM) is a progressive disease that worsens over time if untreated. However, the rate of progression can vary among individuals and may be influenced by various factors, such as the age of the patients, underlying conditions, and the severity and location of the spinal cord compression. Early diagnosis and prompt treatment can help slow the progression of CSM and improve symptoms. There has been an increased use of magnetic resonance imaging (MRI) methods in diagnosing and managing CSM. MRI methods provide detailed images and quantitative structural and functional data of the cervical spinal cord and brain, allowing for an accurate evaluation of the extent and location of tissue injury. This review aims to provide an understanding of the use of MRI methods in interrogating functional and structural changes in the central nervous system in CSM. Further, we identified several challenges hindering the clinical utility of these neuroimaging methods.
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Affiliation(s)
- Ali Fahim Khan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Grace Haynes
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019, USA
| | - Esmaeil Mohammadi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Fauziyya Muhammad
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Sanaa Hameed
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
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Hejrati N, Pedro K, Alvi MA, Quddusi A, Fehlings MG. Degenerative cervical myelopathy: Where have we been? Where are we now? Where are we going? Acta Neurochir (Wien) 2023; 165:1105-1119. [PMID: 37004568 DOI: 10.1007/s00701-023-05558-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/06/2023] [Indexed: 04/04/2023]
Abstract
Degenerative cervical myelopathy (DCM), a recently coined term, encompasses a group of age-related and genetically associated pathologies that affect the cervical spine, including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Given the significant contribution of DCM to global disease and disability, there are worldwide efforts to promote research and innovation in this area. An AO Spine effort termed 'RECODE-DCM' was initiated to create an international multistakeholder consensus group, involving patients, caregivers, physicians and researchers, to focus on launching actionable discourse on DCM. In order to improve the management, treatment and results for DCM, the RECODE-DCM consensus group recently identified ten priority areas for translational research. The current article summarizes recent advancements in the field of DCM. We first discuss the comprehensive definition recently refined by the RECODE-DCM group, including steps taken to arrive at this definition and the supporting rationale. We then provide an overview of the recent advancements in our understanding of the pathophysiology of DCM and modalities to clinically assess and diagnose DCM. A focus will be set on advanced imaging techniques that may offer the opportunity to improve characterization and diagnosis of DCM. A summary of treatment modalities, including surgical and nonoperative options, is then provided along with future neuroprotective and neuroregenerative strategies. This review concludes with final remarks pertaining to the genetics involved in DCM and the opportunity to leverage this knowledge toward a personalized medicine approach.
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Affiliation(s)
- Nader Hejrati
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada.
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Valošek J, Bednařík P, Keřkovský M, Hluštík P, Bednařík J, Svatkova A. Quantitative MR Markers in Non-Myelopathic Spinal Cord Compression: A Narrative Review. J Clin Med 2022; 11:2301. [PMID: 35566426 PMCID: PMC9105390 DOI: 10.3390/jcm11092301] [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: 02/25/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 02/01/2023] Open
Abstract
Degenerative spinal cord compression is a frequent pathological condition with increasing prevalence throughout aging. Initial non-myelopathic cervical spinal cord compression (NMDC) might progress over time into potentially irreversible degenerative cervical myelopathy (DCM). While quantitative MRI (qMRI) techniques demonstrated the ability to depict intrinsic tissue properties, longitudinal in-vivo biomarkers to identify NMDC patients who will eventually develop DCM are still missing. Thus, we aim to review the ability of qMRI techniques (such as diffusion MRI, diffusion tensor imaging (DTI), magnetization transfer (MT) imaging, and magnetic resonance spectroscopy (1H-MRS)) to serve as prognostic markers in NMDC. While DTI in NMDC patients consistently detected lower fractional anisotropy and higher mean diffusivity at compressed levels, caused by demyelination and axonal injury, MT and 1H-MRS, along with advanced and tract-specific diffusion MRI, recently revealed microstructural alterations, also rostrally pointing to Wallerian degeneration. Recent studies also disclosed a significant relationship between microstructural damage and functional deficits, as assessed by qMRI and electrophysiology, respectively. Thus, tract-specific qMRI, in combination with electrophysiology, critically extends our understanding of the underlying pathophysiology of degenerative spinal cord compression and may provide predictive markers of DCM development for accurate patient management. However, the prognostic value must be validated in longitudinal studies.
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Affiliation(s)
- Jan Valošek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (J.V.); (P.H.)
- Department of Radiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic
- Department of Biomedical Engineering, University Hospital Olomouc, 779 00 Olomouc, Czech Republic
| | - Petr Bednařík
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark;
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
| | - Miloš Keřkovský
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; (M.K.); (J.B.)
- Department of Radiology and Nuclear Medicine, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Petr Hluštík
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (J.V.); (P.H.)
- Department of Neurology, University Hospital Olomouc, 779 00 Olomouc, Czech Republic
| | - Josef Bednařík
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; (M.K.); (J.B.)
- Department of Neurology, University Hospital Brno, 625 00 Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic
| | - Alena Svatkova
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark;
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
- Department of Medicine III, Clinical Division of Endocrinology and Metabolism, Medical University of Vienna, 1090 Vienna, Austria
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