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Fazio N, Raiss M, Shah R, Vagal V, Moore M, Chacko M. Diagnostic Challenges in Neuro-Psychiatric Systemic Lupus Erythematosus: A Case of a Patient With Psychosis Secondary to Lupus Cerebritis in the Setting of a Steroid Taper. Cureus 2024; 16:e64484. [PMID: 39139303 PMCID: PMC11319798 DOI: 10.7759/cureus.64484] [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] [Accepted: 07/12/2024] [Indexed: 08/15/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune condition whereby autoantibodies target systemic tissues, causing manifestations of inflammation and tissue damage. Neurologic inflammation in SLE can cause an array of neuropsychiatric (NP) symptoms, including headaches, depression, seizures, demyelinating conditions, mania, and psychosis. Patients treated for SLE are often on anti-inflammatory regimens, including high-dose steroids, which can independently precipitate psychosis. Steroid-induced psychosis (SIP) and lupus cerebritis (LC) are two distinct conditions that patients with SLE may have but often have overlapping presentations, which present a challenge for clinicians. Accurately differentiating between SIP and LC in an emergency setting is crucial for directing appropriate management and preventing potential complications. A clear timeline of the history of symptoms can help narrow down the cause. Diagnostic tools, mainly MRI patterns, can further clarify and indicate the presence of LC. We present a case of a 19-year-old African American female with a history of one steroid-induced psychotic episode five months prior in the setting of SLE who developed subsequent psychosis while on a steroid taper. MRI imaging elucidated a diagnosis of LC rather than a second SIP episode. There are few, if any, case reports that describe a patient with past SIP with a subsequent flare of cerebritis with psychotic symptoms. Strategic approaches to differentiating SIP from LC in the setting of SLE can lead to improved patient outcomes, follow-up care, and an overall understanding of the neuropsychiatric complexities of SLE.
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Affiliation(s)
| | - Monica Raiss
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Ronak Shah
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Vaibhav Vagal
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Maxwell Moore
- Psychiatry, Stony Brook University, Stony Brook, USA
| | - Mason Chacko
- Psychiatry, Stony Brook University, Stony Brook, USA
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2
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Neuropsichiatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2017-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. There are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diffuse and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.
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3
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Greenan-Barrett J, Doolan G, Shah D, Virdee S, Robinson GA, Choida V, Gak N, de Gruijter N, Rosser E, Al-Obaidi M, Leandro M, Zandi MS, Pepper RJ, Salama A, Jury EC, Ciurtin C. Biomarkers Associated with Organ-Specific Involvement in Juvenile Systemic Lupus Erythematosus. Int J Mol Sci 2021; 22:7619. [PMID: 34299237 PMCID: PMC8306911 DOI: 10.3390/ijms22147619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/16/2022] Open
Abstract
Juvenile systemic lupus erythematosus (JSLE) is characterised by onset before 18 years of age and more severe disease phenotype, increased morbidity and mortality compared to adult-onset SLE. Management strategies in JSLE rely heavily on evidence derived from adult-onset SLE studies; therefore, identifying biomarkers associated with the disease pathogenesis and reflecting particularities of JSLE clinical phenotype holds promise for better patient management and improved outcomes. This narrative review summarises the evidence related to various traditional and novel biomarkers that have shown a promising role in identifying and predicting specific organ involvement in JSLE and appraises the evidence regarding their clinical utility, focusing in particular on renal biomarkers, while also emphasising the research into cardiovascular, haematological, neurological, skin and joint disease-related JSLE biomarkers, as well as genetic biomarkers with potential clinical applications.
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Affiliation(s)
- James Greenan-Barrett
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Georgia Doolan
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Devina Shah
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Simrun Virdee
- Department of Ophthalmology, Royal Free Hospital, London NW3 2QG, UK;
| | - George A. Robinson
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Varvara Choida
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Nataliya Gak
- Department of Rheumatology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK; (N.G.); (M.L.)
| | - Nina de Gruijter
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Elizabeth Rosser
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
| | - Muthana Al-Obaidi
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London WC1N 3JH, UK;
- NIHR Biomedical Research Centre, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Maria Leandro
- Department of Rheumatology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK; (N.G.); (M.L.)
- Centre for Rheumatology, Division of Medicine, University College London, London WC1E 6DH, UK;
| | - Michael S. Zandi
- Department of Neurology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK;
| | - Ruth J. Pepper
- Department of Renal Medicine, Royal Free Hospital, University College London, London NW3 2QG, UK; (R.J.P.); (A.S.)
| | - Alan Salama
- Department of Renal Medicine, Royal Free Hospital, University College London, London NW3 2QG, UK; (R.J.P.); (A.S.)
| | - Elizabeth C. Jury
- Centre for Rheumatology, Division of Medicine, University College London, London WC1E 6DH, UK;
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, University College London, London WC1E 6DH, UK; (J.G.-B.); (G.D.); (D.S.); (G.A.R.); (V.C.); (N.d.G.); (E.R.)
- Department of Rheumatology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK; (N.G.); (M.L.)
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Boki K, Katsifis G, Vartela V, Kallenberg CG, Kolovou G, Kitas G. Combined Brain/Heart Magnetic Resonance Imaging in Systemic Lupus Erythematosus. Curr Cardiol Rev 2020; 16:178-186. [PMID: 31368877 PMCID: PMC7536815 DOI: 10.2174/1573403x15666190801122105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022] Open
Abstract
Cardiovascular Disease (CVD) in Systemic Lupus Erythematosus (SLE) and Neuropsychiatric SLE (NPSLE) has an estimated prevalence of 50% and 40%, respectively and both constitute major causes of death among SLE patients. In this review, a combined brain/heart Magnetic Resonance Imaging (MRI) for SLE risk stratification has been proposed. The pathophysiologic background of NPSLE includes microangiopathy, macroscopic infarcts and accelerated atherosclerosis. Classic brain MRI findings demonstrate lesions suggestive of NPSLE in 50% of the NPSLE cases, while advanced MRI indices can detect pre-clinical lesions in the majority of them, but their clinical impact still remains unknown. Cardiac involvement in SLE includes myo-pericarditis, valvular disease/endocarditis, Heart Failure (HF), coronary macro-microvascular disease, vasculitis and pulmonary hypertension. Classic and advanced Cardiovascular Magnetic Resonance (CMR) indices allow function and tissue characterization for early diagnosis and treatment follow-up of CVD in SLE. Although currently, there are no clinical data supporting the combined use of brain/heart MRI in asymptomatic SLE, it may have a place in cases with clinical suspicion of brain/heart involvement, especially in patients at high risk for CVD/stroke such as SLE with antiphospholipid syndrome (SLE/APS), in whom concurrent cardiac and brain lesions have been identified. Furthermore, it may be of value in SLE with multi-organ involvement, NPSLE with concurrent cardiac involvement, and recent onset of arrhythmia and/or heart failure.
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Affiliation(s)
- Sophie Mavrogeni
- Address correspondence to this author at the Onassis Cardiac Surgery Center, FESC, 50 Esperou Street, 175-61 P. Faliro, Athens, Greece; Tel/Fax: +30-210-98.82.797; E-mail:
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Zhuo Z, Su L, Duan Y, Huang J, Qiu X, Haller S, Li H, Zeng X, Liu Y. Different patterns of cerebral perfusion in SLE patients with and without neuropsychiatric manifestations. Hum Brain Mapp 2019; 41:755-766. [PMID: 31650651 PMCID: PMC7268026 DOI: 10.1002/hbm.24837] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/24/2019] [Accepted: 10/09/2019] [Indexed: 11/06/2022] Open
Abstract
To investigate brain perfusion patterns in systemic lupus erythematosus (SLE) patients with and without neuropsychiatric systemic lupus erythematosus (NPSLE and non-NPSLE, respectively) and to identify biomarkers for the diagnosis of NPSLE using noninvasive three-dimensional (3D) arterial spin labeling (ASL). Thirty-one NPSLE and 24 non-NPSLE patients and 32 age- and sex-matched normal controls (NCs) were recruited. Three-dimensional ASL-MRI was applied to quantify cerebral perfusion. Whole brain, gray (GM) and white matter (WM), and voxel-based analysis (VBA) were performed to explore perfusion characteristics. Correlation analysis was performed to find the relationship between the perfusion measures, lesion volumes, and clinical variables. Receiver operating characteristic (ROC) analysis and support vector machine (SVM) classification were applied to differentiate NPSLE patients from non-NPSLE patients and healthy controls. Compared to NCs, NPSLE patients showed increased cerebral blood flow (CBF) within WM but decreased CBF within GM, while non-NPSLE patients showed increased CBF within both GM and WM. Compared to non-NPSLE patients, NPSLE patients showed significantly reduced CBF in the frontal gyrus, cerebellum, and corpus callosum. CBF within several brain regions such as cingulate and corpus callosum showed significant correlations with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Systemic Lupus International Collaborating Clinics (SLICC) damage index scores. ROC analysis showed moderate performance in distinguishing NPSLE from non-NPSLE patients with AUCs > 0.7, while SVM analysis demonstrated that CBF within the corpus callosum achieved an accuracy of 83.6% in distinguishing NPSLE from non-NPSLE patients. Different brain perfusion patterns were observed between NPSLE and non-NPSLE patients. CBF measured by noninvasive 3D ASL could be a useful biomarker for the diagnosis and disease monitoring of NPSLE and non-NPSLE patients.
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Affiliation(s)
- Zhizheng Zhuo
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Li Su
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Yunyun Duan
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Huang
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolu Qiu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Sven Haller
- Department of Imaging and Medical Informatics, University Hospitals of Geneva and Faculty of Medicine of the University of Geneva, Geneva, Switzerland
| | - Haiyun Li
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Yaou Liu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Vieira RM, do Nascimento FBP, Barbosa Júnior AA, Pereira ICMR, Sachetto Z, Appenzeller S, Reis F. Spectrum of central nervous system involvement in rheumatic diseases: pictorial essay. Radiol Bras 2018; 51:262-267. [PMID: 30202131 PMCID: PMC6124581 DOI: 10.1590/0100-3984.2016.0066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The rheumatic diseases, which include systemic lupus erythematosus, rheumatoid
arthritis, Behçet's disease, scleroderma, and ankylosing spondylitis, are
characterized by involvement of connective tissue, with multiple manifestations.
In those diseases, there can be involvement of the peripheral or central nervous
system, and that involvement can be primary, presenting as a major feature of
the clinical presentation, or secondary, as an effect of the drugs used in order
to control a given disease or its complications. Knowledge of the wide variety
of imaging findings is crucial to the diagnosis of a rheumatic disease,
especially in the early stages, enabling effective treatment and minimizing
disability. This pictorial essay, presenting cases from the records of two
tertiary teaching hospitals, encompasses cases of patients diagnosed with
rheumatic disease and illustrates the neuroradiological findings on magnetic
resonance imaging and computed tomography, in order to emphasize the importance
of these methods for properly diagnosing rheumatic diseases.
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Affiliation(s)
- Renata Mendes Vieira
- MD, Resident in Radiology and Diagnostic Imaging at the Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
| | | | - Alcino Alves Barbosa Júnior
- Medical Coordinator of the Neuroradiology Group at the Hospital Israelita Albert Einstein, Professor of Neuromorphology at the Faculdade de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil
| | | | - Zoraida Sachetto
- PhD, Professor in the Department of Internal Medicine of the Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
| | - Simone Appenzeller
- Associate Professor in the Department of Rheumatology of the Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
| | - Fabiano Reis
- PhD, Head of the Neuroradiology Sector, Professor in the Department of Radiology and Diagnostic Imaging of the Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
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Lucic AT. Neuropsichyatric Manifestations of Systemic Lupus Erythematosus: Diagnosis and Treatment Approach. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2017-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus includes heterogeneous manifestations involving both the central and peripheral nervous system. A major issue in clinical evaluation is the attribution of neuropsychiatric symptoms to systemic lupus erithematosus. Antiphospholipid antibodies, immune complex, microangiopathy, early and accelerated arteriosclerosis are factors that have the main role in pathogenesis of neuropsychiatric manifestations of systemic lupus erithematosus. Th ere are no neurological symptoms specific to systemic lupus erithematosus, but they can also occur very commonly in the general population. Lesions of nervous system can be focal or diff use and may be due to systemic lupus erithematosus itself (primary lesions), but it also may be caused by other diseases or disbalances. Therapy of the neuropsychiatric manifestations depends on the nature of the pathological process (dominant inflammation or thrombosis). If it is result of an inflammatory neurotoxic process and in the presence of an increased activity of systemic lupus erithematosus, therapy includes glycocorticoids independently or in combination with immunosuppressives. Focal neuropsychiatric syndrome with antiphospholipid antibodies positivity should be treated with anticoagulant and/ or antiplatelet therapy. In addition, control of classical cardiovascular risk factors, stop smoking, and treatment with hydroxychloroquine is recommended.
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Affiliation(s)
- Alesandra Tomic Lucic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Serbia Internal Clinic, Department of Rheumathology, Clinical Center “ Kragujevac ”, Serbia
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Faria R, Gonçalves J, Dias R. Neuropsychiatric Systemic Lupus Erythematosus Involvement: Towards a Tailored Approach to Our Patients? Rambam Maimonides Med J 2017; 8:RMMJ.10276. [PMID: 28178431 PMCID: PMC5298362 DOI: 10.5041/rmmj.10276] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) is a complex condition that remains poorly understood, and includes heterogeneous manifestations involving both the central and peripheral nervous system, with disabling effects. There are several models to improve NPSLE diagnosis when a neurological syndrome is present. In the last couple of years, the growing knowledge of the role of cytokines and antibodies in NPSLE, as well as the development of new functional imaging techniques, has brought some insights into the physiopathology of the disease, but their validation for clinical use remains undetermined. Furthermore, besides the classic clinical approach, a new tool for screening the 19 NPSLE syndromes has also been developed. Regarding NPSLE therapeutics, there is still no evidence-based treatment approach, but some data support the safety of biological medication when classic treatment fails. Despite the tendency to reclassify SLE patients in clinical and immunological subsets, we hope that these data will inspire medical professionals to approach NPSLE in a manner more tailored to the individual patient.
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Affiliation(s)
- Raquel Faria
- Clinical Immunology Unit, Centro Hospitalar do Porto, Porto, Portugal
- To whom correspondence should be addressed. E-mail:
| | - João Gonçalves
- Medical Service, Centro Hospitalar do Porto, Porto, Portugal
| | - Rita Dias
- Medical Service, Centro Hospitalar do Porto, Porto, Portugal
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Roura E, Sarbu N, Oliver A, Valverde S, González-Villà S, Cervera R, Bargalló N, Lladó X. Automated Detection of Lupus White Matter Lesions in MRI. Front Neuroinform 2016; 10:33. [PMID: 27570507 PMCID: PMC4981618 DOI: 10.3389/fninf.2016.00033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 07/25/2016] [Indexed: 01/14/2023] Open
Abstract
Brain magnetic resonance imaging provides detailed information which can be used to detect and segment white matter lesions (WML). In this work we propose an approach to automatically segment WML in Lupus patients by using T1w and fluid-attenuated inversion recovery (FLAIR) images. Lupus WML appear as small focal abnormal tissue observed as hyperintensities in the FLAIR images. The quantification of these WML is a key factor for the stratification of lupus patients and therefore both lesion detection and segmentation play an important role. In our approach, the T1w image is first used to classify the three main tissues of the brain, white matter (WM), gray matter (GM), and cerebrospinal fluid (CSF), while the FLAIR image is then used to detect focal WML as outliers of its GM intensity distribution. A set of post-processing steps based on lesion size, tissue neighborhood, and location are used to refine the lesion candidates. The proposal is evaluated on 20 patients, presenting qualitative, and quantitative results in terms of precision and sensitivity of lesion detection [True Positive Rate (62%) and Positive Prediction Value (80%), respectively] as well as segmentation accuracy [Dice Similarity Coefficient (72%)]. Obtained results illustrate the validity of the approach to automatically detect and segment lupus lesions. Besides, our approach is publicly available as a SPM8/12 toolbox extension with a simple parameter configuration.
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Affiliation(s)
- Eloy Roura
- Department of Computer Architecture and Technology, University of Girona Girona, Spain
| | - Nicolae Sarbu
- Centre de Diagnòstic per la Imatge, Hospital Clínic Barcelona, Spain
| | - Arnau Oliver
- Department of Computer Architecture and Technology, University of Girona Girona, Spain
| | - Sergi Valverde
- Department of Computer Architecture and Technology, University of Girona Girona, Spain
| | - Sandra González-Villà
- Department of Computer Architecture and Technology, University of Girona Girona, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic-Institut d'Investigació Biomèdica August Pi i Sunyer Barcelona, Spain
| | - Núria Bargalló
- Centre de Diagnòstic per la Imatge, Hospital ClínicBarcelona, Spain; Magnetic Resonance Imaging Core Facility, Institut d'Investigació Biomèdica August Pi i SunyerBarcelona, Spain
| | - Xavier Lladó
- Department of Computer Architecture and Technology, University of Girona Girona, Spain
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