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Reeves JA, Mohebbi M, Zivadinov R, Bergsland N, Dwyer MG, Salman F, Schweser F, Jakimovski D. Reliability of paramagnetic rim lesion classification on quantitative susceptibility mapping (QSM) in people with multiple sclerosis: Single-site experience and systematic review. Mult Scler Relat Disord 2023; 79:104968. [PMID: 37716210 PMCID: PMC11092095 DOI: 10.1016/j.msard.2023.104968] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/15/2023] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Recent developments in iron-sensitive MRI techniques have enabled visualization of chronic active lesions as paramagnetic rim lesions (PRLs) in vivo. Although PRLs have potential as a diagnostic and prognostic tool for multiple sclerosis (MS), limited studies have reported the reliability of PRL assessment. Further evaluation of PRL reliability, through original investigations and review of PRL literature, are warranted. METHODS A single-center cohort study was conducted to evaluate the inter-rater reliability of PRL identification on quantitative susceptibiltiy mapping (QSM) in 10 people with MS, 5 people with clinically isolated syndrome, and 5 healthy controls. An additional systematic literature search was then conducted of published PRL reliability data, and these results were synthesized. RESULTS In the single-center study, both inter-rater and intra-rater reliability of per-subject PRL number were at an "Excellent" (intraclass correlation coefficient (ICC) of 0.901 for both) level with only 2-years lesion classification experience. Across the reported literature values, reliability of per-lesion rim presence was on average "Near perfect" (for intra-rater; Cohen's κ = 0.833) and "Substantial" (for inter-rater; Cohens κ = 0.687), whereas inter-rater reliability of per-subject PRL number was "Good" (ICC = 0.874). Only 4/22 studies reported complete information on rater experience, rater level of training, detailed PRL classification criteria, and reliability cohort size and disease subtypes. CONCLUSION PRLs can be reliably detected both at per-lesion and per-subject level. We recommend that future PRL studies report detailed reliability results, including rater experience level, and use a standardized set of reliability metrics (Cohen's κ or ICC) for improved comparability between studies.
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Affiliation(s)
- Jack A Reeves
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA
| | - Maryam Mohebbi
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA
| | - Michael G Dwyer
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA
| | - Fahad Salman
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA
| | - Ferdinand Schweser
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Buffalo, NY 14203, USA.
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Afkandeh R, Irannejad M, Abedi I, Rabbani M. Automatic detection of active and inactive multiple sclerosis plaques using the Bayesian approach in susceptibility-weighted imaging. Acta Radiol 2022:2841851221143050. [PMID: 36575588 DOI: 10.1177/02841851221143050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Susceptibility-weighted imaging (SWI) is efficient in detecting multiple sclerosis (MS) plaques and evaluating the level of disease activity. PURPOSE To automatically detect active and inactive MS plaques in SWI images using a Bayesian approach. MATERIAL AND METHODS A 1.5-T scanner was used to evaluate 147 patients with MS. The area of the plaques along with their active or inactive status were automatically identified using a Bayesian approach. Plaques were given an orange color if they were active and a blue color if they were inactive, based on the preset signal intensity. RESULTS Experimental findings show that the proposed method has a high accuracy rate of 91% and a sensitivity rate of 76% for identifying the type and area of plaques. Inactive plaques were properly identified in 87% of cases, and active plaques in 76% of cases. The Kappa analysis revealed an 80% agreement between expert diagnoses based on contrast-enhanced and FLAIR images and Bayesian inferences in SWI. CONCLUSION The results of our study demonstrated that the proposed method has good accuracy for identifying the MS plaque area as well as for identifying the types of active or inactive plaques in SWI. Therefore, it might be helpful to use the proposed method as a supplemental tool to accelerate the specialist's diagnosis.
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Affiliation(s)
- Rezvan Afkandeh
- Department of Medical Physics, School of Medicine, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maziar Irannejad
- Department of Electrical Engineering, School of Electrical Engineering, 201564Islamic Azad University Najafabad Branch, Najafabad, Iran
| | - Iraj Abedi
- Department of Medical Physics, School of Medicine, 48455Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Rabbani
- Department of Radiology, School of Medicine, 48455Isfahan University of Medical Sciences, Isfahan, Iran
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Caruana G, Auger C, Pessini LM, Calderon W, de Barros A, Salerno A, Sastre-Garriga J, Montalban X, Rovira À. SWI as an Alternative to Contrast-Enhanced Imaging to Detect Acute MS Lesions. AJNR Am J Neuroradiol 2022; 43:534-539. [PMID: 35332015 PMCID: PMC8993188 DOI: 10.3174/ajnr.a7474] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Acute inflammatory activity of MS lesions is traditionally assessed through contrast-enhanced T1-weighted MR images. The aim of our study was to determine whether a qualitative evaluation of non-contrast-enhanced SWI of new T2-hyperintense lesions might help distinguish acute and chronic lesions and whether it could be considered a possible alternative to gadolinium-based contrast agents for this purpose. MATERIALS AND METHODS Serial MR imaging studies from 55 patients with MS were reviewed to identify 169 new T2-hyperintense lesions. Two blinded neuroradiologists determined their signal pattern on SWI, considering 5 categories (hypointense rings, marked hypointensity, mild hypointensity, iso-/hyperintensity, indeterminate). Two different blinded neuroradiologists evaluated the presence or absence of enhancement in postcontrast T1-weighted images of the lesions. The Fisher exact test was used to determine whether each category of signal intensity on SWI was associated with gadolinium enhancement. RESULTS The presence of hypointense rings or marked hypointensity showed a strong association with the absence of gadolinium enhancement (P < .001), with a sensitivity of 93.0% and a specificity of 82.9%. The presence of mild hypointensity or isohyperintensity showed a strong association with the presence of gadolinium enhancement (P < .001), with a sensitivity of 68.3% and a specificity of 99.2%. CONCLUSIONS A qualitative analysis of the signal pattern on SWI of new T2-hyperintense MS lesions allows determining the likelihood that the lesions will enhance after administration of a gadolinium contrast agent, with high specificity albeit with a moderate sensitivity. While it cannot substitute for the use of contrast agent, it can be useful in some clinical settings in which the contrast agent cannot be administered.
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Affiliation(s)
- G Caruana
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - C Auger
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - L M Pessini
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - W Calderon
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - A de Barros
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - A Salerno
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
| | - J Sastre-Garriga
- Department of Radiology, and Servei de Neurologia-Neuroimmunologia (J.S.-G., X.M.). Centre d'Esclerosi Múltiple de Catalunya, Institut de Recerca Vall d'Hebron, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - X Montalban
- Department of Radiology, and Servei de Neurologia-Neuroimmunologia (J.S.-G., X.M.). Centre d'Esclerosi Múltiple de Catalunya, Institut de Recerca Vall d'Hebron, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - À Rovira
- From the Neuroradiology Section (G.C., C.A., L.M.P., W.C., A.d.B., A.S., À.R.)
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Bahrami M, Rabbani M, Shaygannejad V, Badiei S. Comparison of susceptibility weighted imaging with conventional MRI sequences in multiple sclerosis plaque assessment: A cross-sectional study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2021; 26:128. [PMID: 35126591 PMCID: PMC8772512 DOI: 10.4103/jrms.jrms_726_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/29/2017] [Accepted: 11/09/2018] [Indexed: 11/30/2022]
Abstract
Background: The current study was performed to compare susceptibility-weighted imaging (SWI) with magnetic resonance imaging (MRI) methods of T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR) imaging in multiple sclerosis (MS) plaque assessment Materials and Methods: This cross-sectional study was conducted among 50 MS patients referred to Shafa Imaging Center, Isfahan, Iran. Patients who fulfilled McDonald criteria and were diagnosed with MS by a professional neurologist at least 1 year before the study initiation were included in the study. Eligible patients underwent brain scans using SWI, T2W imaging, and FLAIR. Plaques’ number and volume were detected separately for each imaging sequence. Moreover, identified lesions in SWI sequence were evaluated in terms of iron deposition and central veins Results: Totally 50 patients (10 males and 40 females) with a mean age of 28.48 ± 5.25 years were included in the current study. Majority of patients (60%) had a disease duration of >5 years, and mean expanded disability status score was 2.56 ± 1.32. There was no significant difference between different imaging modalities in terms of plaques’ number and volume (P > 0.05). It was also found that there was a high correlation between SWI and conventional imaging techniques of T2W (r = 0.97, 0.91, P < 0.001) and FLAIR (r = 0.99, 0.99, P < 0.001) in the estimation of both the number and volume of plaques (P < 0.001) Conclusion: The results of the present study indicated that SWI and conventional MRI sequences have similar efficiency for plaque assessment in MS patients.
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G H M, G PJ, A A, P G. Detection of Active Plaques in Multiple Sclerosis using 3 and 12 Directional Diffusion-weighted Imaging: Comparison with Gadolinium-enhanced MR Imaging. J Biomed Phys Eng 2020; 10:737-744. [PMID: 33364211 PMCID: PMC7753260 DOI: 10.31661/jbpe.v0i0.925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/10/2018] [Indexed: 11/16/2022]
Abstract
Background Multiple Sclerosis (MS), distinguished by aggravating the function of central nervous system because of inflammatory demyelination. The most sensitive method for MS diagnosis is Magnetic resonance imaging (MRI). To distinguish inactive and active MS lesions, contrast-enhanced T1-weighted imaging (CE T1WI) is being used as a gold standard. There are some contraindications in gadolinium based contrast agents (GBCAs) usage. Moreover, diffusion-weighted imaging (DWI) can discover diffusion changes involved inflammatory lesions. Objective The current research aims at investigating if typical DWI (3 directional) and 12 directional DWI could be a substitute for CE T1WI in order to show active lesions of MS. Material and Methods In this cross-sectional study, 138 patients with CNS symptoms were examined. For all patients, along with CE T1WI, 3 & 12 directional DWI were performed. Intraclass correlation coefficient (ICC), receiver operating characteristic (ROC), the sensitivity versus specificity plot and the area under the curve (AUC) were calculated. Results There was a contrast enhancement in CE T1WI for 114 patients (82.6%); in addition, hyper-intense lesions on DWI 3 and DWI 12 were shown in 107 (77.5%) and 117 patients (84.7%) in order. Sensitivity, specificity and AUC were 94.7%, 62.5% and 84% for DWI 12. Moreover, the results were 86%, 62.5 and 79% for the sensitivity, specificity and AUC for DWI 3 respectively. Conclusion In spite of lower sensitivity of 12 directional DWI compared to CE T1WI, it could be used as a diagnostic sequence in differentiating enhanced lesions from non-enhanced ones when CE-MRI is a worry.
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Affiliation(s)
- Meftahi G H
- PhD, Neuroscience Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Pirzad Jahromi G
- PhD, Neuroscience Research Centre, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Azari A
- BSc, Radiology Department, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ghaemmaghami P
- PhD, Biostatistics Department, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Lamot U, Avsenik J, Šega S, Šurlan Popovič K. Presence of central veins and susceptibility weighted imaging for evaluating lesions in multiple sclerosis and leukoaraiosis. Mult Scler Relat Disord 2017; 13:67-72. [DOI: 10.1016/j.msard.2017.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/27/2017] [Accepted: 02/10/2017] [Indexed: 01/03/2023]
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Mehemed TM, Yamamoto A, Okada T, Kanagaki M, Sawada T, Morimoto E, Takahashi JC, Miyamoto S, Togashi K. Analysis of susceptibility-weighted images of cortico-medullary junction. Magn Reson Med Sci 2014; 13:231-8. [PMID: 25167876 DOI: 10.2463/mrms.2013-0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We qualitatively evaluated the differences among susceptibility-weighted (SWI), magnitude (MAG), and high pass filtered phase (PHA) images in depicting interlobar differences in the appearance of the signal of the corticomedullary junction (CMJ). We conducted quantitative evaluation to validate the qualitative results. MATERIALS AND METHODS We obtained SWI images from 25 preoperative brain tumor patients (12 men, 13 women, aged 19 to 82 years, mean, 52 years). Two trained neuroradiologists evaluated MAG, PHA, and SWI images. Qualitative evaluation of the CMJ signal and quantitative calculation of the relative signal ratio (RSR) percentages between the CMJ and deep white matter (WM) were conducted at 3 different slice levels of the brain independently for 4 different lobes (frontal, parietal, temporal, and occipital) and compared among MAG, PHA, and SWI. The extent of the area of the CMJ signal was graded on a 4-point scale (Grade 3, >75%; Grade 2, 50 to 75%; Grade 1, 25 to 50%; Grade 0, <25%). Data were statistically analyzed using a nonparametric Friedman test. RESULTS The Kappa coefficients between the qualitative and quantitative grades were 0.002 for MAG, 0.0047 for PHA, and 0.050 for SWI. Qualitatively, on the PHA images and SWI, grades of the occipital lobes were significantly higher than those of the other lobes (P < 0.005). Quantitatively, PHA images showed statistically significant interlobar differences in RSR percentage values of the CMJ (P = 0.025). CONCLUSION Qualitatively, the appearance of the CMJ differed significantly among the different lobes of the brain on SWI and underlying PHA images but not on MAG images. Quantitatively, only PHA images showed significant interlobar differences in the RSR. PHA images are most sensitive to the CMJ signal contrast due to local paramagnetic iron content.
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Affiliation(s)
- Taha M Mehemed
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University
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Absinta M, Sati P, Gaitán MI, Maggi P, Cortese ICM, Filippi M, Reich DS. Seven-tesla phase imaging of acute multiple sclerosis lesions: a new window into the inflammatory process. Ann Neurol 2013; 74:669-78. [PMID: 23813441 PMCID: PMC3812397 DOI: 10.1002/ana.23959] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 04/15/2013] [Accepted: 05/28/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE In multiple sclerosis (MS), accurate, in vivo characterization of dynamic inflammatory pathological changes occurring in newly forming lesions could have major implications for understanding disease pathogenesis and mechanisms of tissue destruction. Here, we investigated the potential of ultrahigh-field magnetic resonance imaging (MRI; 7T), particularly phase imaging combined with dynamic contrast enhancement, to provide new insights in acute MS lesions. METHODS Sixteen active MS patients were studied at 7T. Noncontrast, high-resolution T2* magnitude and phase scans, T1 scans before/after gadolinium contrast injection, and dynamic contrast-enhanced (DCE) T1 scans were acquired. T2*/phase features and DCE pattern were determined for acute and chronic lesions. When possible, 1-year follow-up 7T MRI was performed. RESULTS Of 49 contrast-enhancing lesions, 44 could be analyzed. Centrifugal DCE lesions appeared isointense or hypointense on phase images, whereas centripetal DCE lesions showed thin, hypointense phase rims that clearly colocalized with the initial site of contrast enhancement. This pattern generally disappeared once enhancement resolved. Conversely, in 43 chronic lesions also selected for the presence of hypointense phase rims, the findings were stable over time, and the rims were typically thicker and darker. These considerations suggest different underlying pathological processes in the 2 lesion types. INTERPRETATION Ultrahigh-field MRI and, especially, phase contrast, are highly sensitive to tissue changes in acute MS lesions, which differ from the patterns seen in chronic lesions. In acute lesions, the hypointense phase rim reflects the expanding inflammatory edge and may directly correspond to inflammatory byproducts and sequelae of blood-brain barrier opening.
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Affiliation(s)
- Martina Absinta
- Translational Neuroradiology Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Neuroimaging Research Unit, Institute of Experimental Neurology, Division of Neuroscience, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Wuerfel J, Sinnecker T, Ringelstein EB, Jarius S, Schwindt W, Niendorf T, Paul F, Kleffner I, Dörr J. Lesion morphology at 7 Tesla MRI differentiates Susac syndrome from multiple sclerosis. Mult Scler 2012; 18:1592-9. [DOI: 10.1177/1352458512441270] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Although an orphan disease with still obscure aetiopathogenesis, Susac syndrome has to be considered as differential diagnosis in multiple sclerosis (MS), since its clinical presentation and paraclinical features including routine magnetic resonance imaging (MRI) findings partially overlap. Objective: We aimed to study a potential benefit of 7T MRI for (i) the differentiation between Susac syndrome and MS and (ii) the clarification of pathogenesis of Susac syndrome. Methods: Five patients suffering from Susac syndrome, 10 sex- and age-matched patients with relapsing–remitting MS (median Expanded Disability Status Scale (EDSS) score 1.5) and 15 matching healthy controls were investigated at 7 Tesla MRI. The protocol included T1-weighted MPRAGE, T2*-weighted FLASH, and TIRM sequences. Results: Almost all T2* FLASH lesions in patients with MS were centred by a small central vein (325 lesions; 92%) and often showed a small hypointense rim (145 lesions; 41%). In contrast, white matter lesions in Susac syndrome exhibited a perivascular setting significantly less frequently (148 lesions; 54%, p=0.002), and very rarely exhibited a hypointense rim (12 lesions; 4%, p=0.004). Furthermore, in addition to callosal atrophy, Susac patients showed cerebrospinal fluid-isointense lesions within the central part of corpus callosum that are not commonly seen in MS. Conclusion: At 7T MRI, plaques in MS patients and patients with Susac syndrome differed substantially with respect to morphology and pattern. Thus, lesion morphology at 7T (i) may serve as a marker to distinguish Susac syndrome from MS and (ii) reflects a different pathophysiological mechanism underlying Susac syndrome, for example microinfarction rather than demyelination.
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Affiliation(s)
- Jens Wuerfel
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Ultrahigh Field Facility, Max Delbrueck Center for Molecular Medicine, Germany
- Institute of Neuroradiology, University of Luebeck, Germany
| | - Tim Sinnecker
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Sven Jarius
- Division of Molecular Neuroimmunology, Department of Neurology, University Hospital Heidelberg, Germany
| | | | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility, Max Delbrueck Center for Molecular Medicine, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Germany
| | - Ilka Kleffner
- Department of Neurology, University of Münster, Germany
| | - Jan Dörr
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Clinical and Experimental Multiple Sclerosis Research Center, Charité-Universitätsmedizin Berlin, Germany
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