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Bouisset N, Nissi J, Laakso I, Reynolds RF, Legros A. Is activation of the vestibular system by electromagnetic induction a possibility in an MRI context? Bioelectromagnetics 2024; 45:171-183. [PMID: 38348647 DOI: 10.1002/bem.22497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/21/2023] [Accepted: 12/16/2023] [Indexed: 04/17/2024]
Abstract
In recent years, an increasing number of studies have discussed the mechanisms of vestibular activation in strong magnetic field settings such as occur in a magnetic resonance imaging scanner environment. Amid the different hypotheses, the Lorentz force explanation currently stands out as the most plausible mechanism, as evidenced by activation of the vestibulo-ocular reflex. Other hypotheses have largely been discarded. Nonetheless, both human data and computational modeling suggest that electromagnetic induction could be a valid mechanism which may coexist alongside the Lorentz force. To further investigate the induction hypothesis, we provide, herein, a first of its kind dosimetric analysis to estimate the induced electric fields at the vestibular system and compare them with what galvanic vestibular stimulation would generate. We found that electric fields strengths from induction match galvanic vestibular stimulation strengths generating vestibular responses. This review examines the evidence in support of electromagnetic induction of vestibular responses, and whether movement-induced time-varying magnetic fields should be further considered and investigated.
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Affiliation(s)
- Nicolas Bouisset
- Human Threshold Research Group, Lawson Health Research Institute, London, Ontario, Canada
- School of Kinesiology, Western University, London, Ontario, Canada
| | - Janita Nissi
- Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland
| | - Ilkka Laakso
- Department of Electrical Engineering and Automation, Aalto University, Espoo, Finland
| | - Raymond F Reynolds
- School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Alexandre Legros
- Human Threshold Research Group, Lawson Health Research Institute, London, Ontario, Canada
- School of Kinesiology, Western University, London, Ontario, Canada
- EuroMov Digital Health in Motion, Univ Montpellier, IMT Mines Ales, Montpellier, France
- Departments of Medical Biophysics and Medical Imaging Western University, London, Ontario, Canada
- Eurostim, Montpellier, France
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Seo JH, Jo YS, Oh CH, Chung JY. A New Combination of Radio-Frequency Coil Configurations Using High-Permittivity Materials and Inductively Coupled Structures for Ultrahigh-Field Magnetic Resonance Imaging. SENSORS (BASEL, SWITZERLAND) 2022; 22:8968. [PMID: 36433565 PMCID: PMC9694602 DOI: 10.3390/s22228968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/03/2022] [Accepted: 11/17/2022] [Indexed: 06/16/2023]
Abstract
In ultrahigh-field (UHF) magnetic resonance imaging (MRI) system, the RF power required to excite the nuclei of the target object increases. As the strength of the main magnetic field (B0 field) increases, the improvement of the RF transmit field (B1+ field) efficiency and receive field (B1- field) sensitivity of radio-frequency (RF) coils is essential to reduce their specific absorption rate and power deposition in UHF MRI. To address these problems, we previously proposed a method to simultaneously improve the B1+ field efficiency and B1- field sensitivity of 16-leg bandpass birdcage RF coils (BP-BC RF coils) by combining a multichannel wireless RF element (MCWE) and segmented cylindrical high-permittivity material (scHPM) comprising 16 elements in 7.0 T MRI. In this work, we further improved the performance of transmit/receive RF coils. A new combination of RF coil with wireless element and HPM was proposed by comparing the BP-BC RF coil with the MCWE and the scHPM proposed in the previous study and the multichannel RF coils with a birdcage RF coil-type wireless element (BCWE) and the scHPM proposed in this study. The proposed 16-ch RF coils with the BCWE and scHPM provided excellent B1+ field efficiency and B1- field sensitivity improvement.
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Affiliation(s)
- Jeung-Hoon Seo
- Neuroscience Research Institute, Gachon University, Incheon 21988, Republic of Korea
| | - Young-Seung Jo
- Neuroscience Research Institute, Gachon University, Incheon 21988, Republic of Korea
- Department of Electronics and Information Engineering, Korea University, Sejong 30019, Republic of Korea
| | - Chang-Hyun Oh
- Department of Electronics and Information Engineering, Korea University, Sejong 30019, Republic of Korea
| | - Jun-Young Chung
- Department of Neuroscience, College of Medicine, Gachon University, Incheon 21565, Republic of Korea
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Okada T, Fujimoto K, Fushimi Y, Akasaka T, Thuy DHD, Shima A, Sawamoto N, Oishi N, Zhang Z, Funaki T, Nakamoto Y, Murai T, Miyamoto S, Takahashi R, Isa T. Neuroimaging at 7 Tesla: a pictorial narrative review. Quant Imaging Med Surg 2022; 12:3406-3435. [PMID: 35655840 PMCID: PMC9131333 DOI: 10.21037/qims-21-969] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/05/2022] [Indexed: 01/26/2024]
Abstract
Neuroimaging using the 7-Tesla (7T) human magnetic resonance (MR) system is rapidly gaining popularity after being approved for clinical use in the European Union and the USA. This trend is the same for functional MR imaging (MRI). The primary advantages of 7T over lower magnetic fields are its higher signal-to-noise and contrast-to-noise ratios, which provide high-resolution acquisitions and better contrast, making it easier to detect lesions and structural changes in brain disorders. Another advantage is the capability to measure a greater number of neurochemicals by virtue of the increased spectral resolution. Many structural and functional studies using 7T have been conducted to visualize details in the white matter and layers of the cortex and hippocampus, the subnucleus or regions of the putamen, the globus pallidus, thalamus and substantia nigra, and in small structures, such as the subthalamic nucleus, habenula, perforating arteries, and the perivascular space, that are difficult to observe at lower magnetic field strengths. The target disorders for 7T neuroimaging range from tumoral diseases to vascular, neurodegenerative, and psychiatric disorders, including Alzheimer's disease, Parkinson's disease, multiple sclerosis, epilepsy, major depressive disorder, and schizophrenia. MR spectroscopy has also been used for research because of its increased chemical shift that separates overlapping peaks and resolves neurochemicals more effectively at 7T than a lower magnetic field. This paper presents a narrative review of these topics and an illustrative presentation of images obtained at 7T. We expect 7T neuroimaging to provide a new imaging biomarker of various brain disorders.
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Affiliation(s)
- Tomohisa Okada
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Fujimoto
- Department of Real World Data Research and Development, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasutaka Fushimi
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Thai Akasaka
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Dinh H. D. Thuy
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Shima
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobukatsu Sawamoto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoya Oishi
- Medial Innovation Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Zhilin Zhang
- Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Funaki
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshiya Murai
- Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadashi Isa
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
After introduction of the first human 7 tesla (7T) system in 1999, 7T MR systems have been employed as one of the most advanced platforms for human MR research for more than 20 years. Currently, two 7T MR models are approved for clinical use in the U.S.A. The approval facilitated introduction of the 7T system, summing up to around 100 worldwide. The approval in Japan is much awaited. As a clinical MR scanner, the 7T MR system is drawing attention in terms of safety.Several large-sized studies on bioeffects have been reported for vertigo, dizziness, motion disturbances, nausea, and others. Such effects might also be found in MR workers and researchers. Frequency and severity of reported bioeffects will be presented and discussed, including their variances. The high resonance frequency and shorter RF wavelength of 7T increase the concern about the safety. Homogeneous RF pulse excitation is difficult even for the brain, and a multi-channel parallel transmit (pTx) system is considered mandatory. However, pTx may create a hot spot, which makes the estimation of specific absorption rate (SAR) to be difficult. The stronger magnetic field of 7T causes a large force of displacement and heating on metallic implants or devices, and the scan of patients with them should not be conducted at 7T. However, there are some opinions that such patients might be scanned even at 7T, if certain criteria are met. This article provides a brief review on the effect of the static magnetic field on humans (MR subjects, workers, and researchers) and neurons, in addition to scan sound, SAR, and metal implants and devices. Understanding and avoiding adverse effects will contribute to the reduction in safety risks and the prevention of incidents.
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Affiliation(s)
- Tomohisa Okada
- Human Brain Research Center, Graduate School of Medicine, Kyoto University
| | - Thai Akasaka
- Human Brain Research Center, Graduate School of Medicine, Kyoto University
| | - Dinh Hd Thuy
- Human Brain Research Center, Graduate School of Medicine, Kyoto University
| | - Tadashi Isa
- Human Brain Research Center, Graduate School of Medicine, Kyoto University
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Abstract
Clinical MRI systems have continually improved over the years since their introduction in the 1980s. In MRI technical development, the developments in each MRI system component, including data acquisition, image reconstruction, and hardware systems, have impacted the others. Progress in each component has induced new technology development opportunities in other components. New technologies outside of the MRI field, for example, computer science, data processing, and semiconductors, have been immediately incorporated into MRI development, which resulted in innovative applications. With high performance computing and MR technology innovations, MRI can now provide large volumes of functional and anatomical image datasets, which are important tools in various research fields. MRI systems are now combined with other modalities, such as positron emission tomography (PET) or therapeutic devices. These hybrid systems provide additional capabilities. In this review, MRI advances in the last two decades will be considered. We will discuss the progress of MRI systems, the enabling technology, established applications, current trends, and the future outlook.
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Affiliation(s)
- Hiroyuki Kabasawa
- Department of Radiological Sciences, School of Health Sciences at Narita, International University of Health and Welfare
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Tkáč I, Benneyworth MA, Nichols-Meade T, Steuer EL, Larson SN, Metzger GJ, Uğurbil K. Long-term behavioral effects observed in mice chronically exposed to static ultra-high magnetic fields. Magn Reson Med 2021; 86:1544-1559. [PMID: 33821502 DOI: 10.1002/mrm.28799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/11/2021] [Accepted: 03/19/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The primary goal of this study was to investigate whether chronic exposures to ultra-high B0 fields can induce long-term cognitive, behavioral, or biological changes in C57BL/6 mice. METHODS C57BL/6 mice were chronically exposed to 10.5-T or 16.4-T magnetic fields (3-h exposures, two exposure sessions per week, 4 or 8 weeks of exposure). In vivo single-voxel 1 H magnetic resonance spectroscopy was used to investigate possible neurochemical changes in the hippocampus. In addition, a battery of behavioral tests, including the Morris water-maze, balance-beam, rotarod, and fear-conditioning tests, were used to examine long-term changes induced by B0 exposures. RESULTS Hippocampal neurochemical profile, cognitive, and basic motor functions were not impaired by chronic magnetic field exposures. However, the balance-beam-walking test and the Morris water-maze testing revealed B0 -induced changes in motor coordination and balance. The tight-circling locomotor behavior during Morris water-maze tests was found as the most sensitive factor indexing B0 -induced changes. Long-term behavioral changes were observed days or even weeks subsequent to the last B0 exposure at 16.4 T but not at 10.5 T. Fast motion of mice in and out of the 16.4-T magnet was not sufficient to induce such changes. CONCLUSION Observed results suggest that the chronic exposure to a magnetic field as high as 16.4 T may result in long-term impairment of the vestibular system in mice. Although observation of mice may not directly translate to humans, nevertheless, they indicate that studies focused on human safety at very high magnetic fields are necessary.
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Affiliation(s)
- Ivan Tkáč
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael A Benneyworth
- Mouse Behavioral Core, Department of Neuroscience, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tessa Nichols-Meade
- Mouse Behavioral Core, Department of Neuroscience, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth L Steuer
- N Bud Grossman Center for Memory Research & Care, Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah N Larson
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregory J Metzger
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kâmil Uğurbil
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
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Fuhrer E, Jouda M, Klein CO, Wilhelm M, Korvink JG. Gradient-Induced Mechanical Vibration of Neural Interfaces During MRI. IEEE Trans Biomed Eng 2019; 67:915-923. [PMID: 31226065 DOI: 10.1109/tbme.2019.2923693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Resonant vibrations of implanted structures during a magnetic resonance imaging (MRI) procedure pose a risk to the patient in the form of soft tissue irritation and degradation of the implant. In this paper, the mechanical behavior of implant structures in air, water, and viscoelastic materials was explored. METHODS The static and dynamic transfer functions of various test samples in air and immersed in both water and hydrogels were analyzed. The laser-based acquisition method allowed for high-angular-resolution (10 μDeg) and high-dynamic-range (0-6 kHz) measurements. Additional MRI experiments were conducted to investigate the dependence of vibration strength on magnetic resonance (MR) sequence parameters in combination with the obtained transfer functions. RESULTS The largest forces were found to be in the micronewton to millinewton range, which is comparable to forces applied during implantation. Of additional concern was the damping introduced by viscoelastic tissue, which was less than expected, leading to an underdamped system. In contrast to current wisdom, the imaging experiments demonstrated drastically different vibration amplitudes for identical gradient slew rates, but different timing parameters TR, mainly due to resonant amplification. CONCLUSION The results showed that a safe force-free MR procedure depends not only on the gradient slew rate, but also and more drastically on the choice of secure timing parameters. SIGNIFICANCE These findings delineate design improvements to achieve longevity of implants and will lead to increased patient safety during MRI. A prudent choice of mechanical characteristics of implanted structures is sufficient to avoid resonant excitation due to mismatched MR sequence parameters.
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Hidaka S, Higuchi S, Teramoto W, Sugita Y. Neural mechanisms underlying sound-induced visual motion perception: An fMRI study. Acta Psychol (Amst) 2017; 178:66-72. [PMID: 28600968 DOI: 10.1016/j.actpsy.2017.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 05/17/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022] Open
Abstract
Studies of crossmodal interactions in motion perception have reported activation in several brain areas, including those related to motion processing and/or sensory association, in response to multimodal (e.g., visual and auditory) stimuli that were both in motion. Recent studies have demonstrated that sounds can trigger illusory visual apparent motion to static visual stimuli (sound-induced visual motion: SIVM): A visual stimulus blinking at a fixed location is perceived to be moving laterally when an alternating left-right sound is also present. Here, we investigated brain activity related to the perception of SIVM using a 7T functional magnetic resonance imaging technique. Specifically, we focused on the patterns of neural activities in SIVM and visually induced visual apparent motion (VIVM). We observed shared activations in the middle occipital area (V5/hMT), which is thought to be involved in visual motion processing, for SIVM and VIVM. Moreover, as compared to VIVM, SIVM resulted in greater activation in the superior temporal area and dominant functional connectivity between the V5/hMT area and the areas related to auditory and crossmodal motion processing. These findings indicate that similar but partially different neural mechanisms could be involved in auditory-induced and visually-induced motion perception, and neural signals in auditory, visual, and, crossmodal motion processing areas closely and directly interact in the perception of SIVM.
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ORISO K, KOBAYASHI T, SASAKI M, UWANO I, KIHARA H, KONDO H. Impact of the Static and Radiofrequency Magnetic Fields Produced by a 7T MR Imager on Metallic Dental Materials. Magn Reson Med Sci 2016; 15:26-33. [DOI: 10.2463/mrms.2014-0122] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kenta ORISO
- Department of Prosthodontics and Oral Implantology, Iwate Medical University
| | - Takuya KOBAYASHI
- Department of Prosthodontics and Oral Implantology, Iwate Medical University
| | - Makoto SASAKI
- Division of Ultrahigh Field MRI, Institute of Biomedical Sciences, Iwate Medical University
| | - Ikuko UWANO
- Division of Ultrahigh Field MRI, Institute of Biomedical Sciences, Iwate Medical University
| | - Hidemichi KIHARA
- Department of Prosthodontics and Oral Implantology, Iwate Medical University
| | - Hisatomo KONDO
- Department of Prosthodontics and Oral Implantology, Iwate Medical University
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Klix S, Els A, Paul K, Graessl A, Oezerdem C, Weinberger O, Winter L, Thalhammer C, Huelnhagen T, Rieger J, Mehling H, Schulz-Menger J, Niendorf T. On the subjective acceptance during cardiovascular magnetic resonance imaging at 7.0 Tesla. PLoS One 2015; 10:e0117095. [PMID: 25621491 PMCID: PMC4306482 DOI: 10.1371/journal.pone.0117095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/18/2014] [Indexed: 12/25/2022] Open
Abstract
PURPOSE This study examines the subjective acceptance during UHF-CMR in a cohort of healthy volunteers who underwent a cardiac MR examination at 7.0T. METHODS Within a period of two-and-a-half years (January 2012 to June 2014) a total of 165 healthy volunteers (41 female, 124 male) without any known history of cardiac disease underwent UHF-CMR. For the assessment of the subjective acceptance a questionnaire was used to examine the participants experience prior, during and after the UHF-CMR examination. For this purpose, subjects were asked to respond to the questionnaire in an exit interview held immediately after the completion of the UHF-CMR examination under supervision of a study nurse to ensure accurate understanding of the questions. All questions were answered with "yes" or "no" including space for additional comments. RESULTS Transient muscular contraction was documented in 12.7% of the questionnaires. Muscular contraction was reported to occur only during periods of scanning with the magnetic field gradients being rapidly switched. Dizziness during the study was reported by 12.7% of the subjects. Taste of metal was reported by 10.1% of the study population. Light flashes were reported by 3.6% of the entire cohort. 13% of the subjects reported side effects/observations which were not explicitly listed in the questionnaire but covered by the question about other side effects. No severe side effects as vomiting or syncope after scanning occurred. No increase in heart rate was observed during the UHF-CMR exam versus the baseline clinical examination. CONCLUSIONS This study adds to the literature by detailing the subjective acceptance of cardiovascular magnetic resonance imaging examinations at a magnetic field strength of 7.0T. Cardiac MR examinations at 7.0T are well tolerated by healthy subjects. Broader observational and multi-center studies including patient cohorts with cardiac diseases are required to gain further insights into the subjective acceptance of UHF-CMR examinations.
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Affiliation(s)
- Sabrina Klix
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Antje Els
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Katharina Paul
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Andreas Graessl
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Celal Oezerdem
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Oliver Weinberger
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Lukas Winter
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Christof Thalhammer
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Till Huelnhagen
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Jan Rieger
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Heidrun Mehling
- Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
| | - Jeanette Schulz-Menger
- Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
- HELIOS Klinikum Berlin-Buch, Dept. of Cardiology and Nephrology, 13125 Berlin, Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
- Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max-Delbrueck-Center for Molecular Medicine, Berlin, Germany
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