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Blache A, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, James D, Dejean C, Dapké S, Devauchelle B, Thariat J. [Issues and implementation of postoperative radiotherapy after flap reconstructive surgery in head and neck cancers]. Bull Cancer 2024; 111:496-504. [PMID: 38553286 DOI: 10.1016/j.bulcan.2024.02.002] [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] [Received: 11/05/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 05/13/2024]
Abstract
The management of head and neck cancers is multidisciplinary, often relying on the use of combined treatments to maximize the chances of cure. Combined treatments are however also responsible for cumulative side effects. The aim of reconstructive surgery with a flap is to restore a function lost with the loss of substance from the tumor resection. However, changes in reconstructive surgery have impact of postoperative radiotherapy planning. The optimization of imaging protocols for radiotherapy planning should make it possible to identify postoperative changes and to distinguish flaps from surrounding native tissues to delineate the flaps and document the spontaneous evolution of these flaps or dose-effect relationships in case of radiotherapy. Such changes include atrophy, fibrosis of soft tissue flaps and osteoradionecrosis of bone flaps. Radiotherapy optimization also involves standardization of the definition of target volumes in situations where a flap is present, a situation that is increasingly common in routine care. This evolution of practice, beyond the essential multidisciplinary consultation meetings defining treatment indications, requires a close radio surgical collaboration with respect to technical aspects of the two disciplines. Doing so, anticipation of relapse and toxicity profiles could possibly lead to propose strategies for personalized de-escalation of multimodal treatments through interdisciplinary trials.
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Affiliation(s)
- Alice Blache
- Département de radiothérapie, centre hospitalier universitaire Amiens-Picardie, 80000 Amiens, France.
| | - Florent Carsuzaa
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | | | - Sophie Deneuve
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital of Rouen, Poitiers, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Quartier Quiez, 83189 Ollioules, France
| | - Dylan James
- Radiotherapy Department, University Hospital of Brest, Brest, France
| | | | - Stéphanie Dapké
- Departement of Maxillofacial Surgery, Research Unit, UR7516 CHIMERE, University of Picardy Jules-Verne, Institut Faire Faces, University Hospital of Amiens Picardy, Amiens Picardy, France
| | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, Research Unit, UR7516 CHIMERE, University of Picardy Jules-Verne, Institut Faire Faces, University Hospital of Amiens Picardy, Amiens Picardy, France
| | - Juliette Thariat
- Department of radiotherapy, Centre François-Baclesse, Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Université de Normandie, GORTEC, Caen, France
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Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [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] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
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Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
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Bhatt AA, Vibhute P, Wu XC, Escott EJ, Chung C, Rhyner PA. Cervical Osteomyelitis and Diskitis as a Complication of Neopharyngeal Breakdown: A Multisite Case Series Review. AJNR Am J Neuroradiol 2023; 44:1418-1420. [PMID: 37945524 PMCID: PMC10714855 DOI: 10.3174/ajnr.a8042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/27/2023] [Indexed: 11/12/2023]
Abstract
Laryngectomy and pharyngectomy are surgical options for advanced laryngeal or pharyngeal squamous cell carcinoma. Cervical osteomyelitis-diskitis, occurring when there is dehiscence of the posterior neopharyngeal wall, is an uncommon complication of laryngopharyngectomy. This case series describes imaging findings of pharyngoesophageal wall breakdown with subsequent cervical spine infection and demonstrates that most of these patients had undergone prior esophageal or neopharyngeal dilations for benign posttreatment stricture. Neck pain, fever, or serologic evidence of infection should prompt careful evaluation for osteomyelitis-diskitis and assessment for neopharyngeal breakdown and sinus tract formation, especially in the postdilation setting.
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Affiliation(s)
- Alok A Bhatt
- From the Department of Radiology (A.A.B., P.V., P.A.R.), Mayo Clinic, Jacksonville, Florida
| | - Prasanna Vibhute
- From the Department of Radiology (A.A.B., P.V., P.A.R.), Mayo Clinic, Jacksonville, Florida
| | - Xin Cynthia Wu
- Department of Radiology (X.C.W.), University of California, San Francisco, San Francisco, California
| | - Edward J Escott
- Department of Radiology (E.J.E.), University of Kentucky, Lexington, Kentucky
| | - Charlotte Chung
- Department of Radiology (C.C.), New York University Langone Health, New York, New York
| | - Patricia A Rhyner
- From the Department of Radiology (A.A.B., P.V., P.A.R.), Mayo Clinic, Jacksonville, Florida
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Beck RT, Rath T, Gill S, Zenga J, Agarwal M. Demystifying Surgical Free Flaps in the Head and Neck. Semin Roentgenol 2023; 58:301-310. [PMID: 37507171 DOI: 10.1053/j.ro.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/16/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Ryan T Beck
- Froedtert and Medical College of Wisconsin, Milwaukee, WI
| | - Tanya Rath
- Mayo Clinic College of Medicine, Phoenix, AZ
| | - Sonia Gill
- Froedtert and Medical College of Wisconsin, Milwaukee, WI
| | - Joseph Zenga
- Froedtert and Medical College of Wisconsin, Milwaukee, WI
| | - Mohit Agarwal
- Froedtert and Medical College of Wisconsin, Milwaukee, WI.
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Ota Y, Curaudeau G, Liao E, Bapuraj J, Baba A, Shah G, Srinivasan A. Precise differentiation between jugular foramen paragangliomas and metastases: utility of diffusion-weighted and dynamic contrast-enhanced magnetic resonance imaging. Neuroradiology 2023; 65:805-813. [PMID: 36635515 DOI: 10.1007/s00234-023-03113-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/04/2023] [Indexed: 01/14/2023]
Abstract
PURPOSE This study tested the utility of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced imaging (DCE-MRI) in differentiating paragangliomas and metastases in the jugular foramen in combination with conventional imaging. METHODS Forty-nine consecutive patients with paragangliomas or metastases between January 2015 and April 2022 were included in this retrospective study. All patients had pretreatment DWI and DCE-MRI. Between paragangliomas and metastases, normalized apparent diffusion coefficient (nADCmean) and DCE-MRI parameters were compared along with conventional imaging features (enhancement pattern, presence of flow voids, cystic/necrotic change, and bone erosion). The diagnostic performance was tested using receiver operating characteristic (ROC) analysis. RESULTS Thirty-five paragangliomas (5 male; median 49 years) and 14 metastases (9 male; median 61 years) were analyzed. The most common 3 primary cancers included 4 lung cancers, 3 breast cancers, and 3 melanomas. The presence of flow void was significantly different between paragangliomas and metastases (21/35 vs 2/14; P = 0.0047) in conventional imaging features, while fractional plasma volume (Vp) was significantly different between the two tumor types (median 0.46 vs 0.19; P < 0.001) in DWI and DCE-MRI parameters. The areas under the ROC curves (AUCs) of the presence of flow void and Vp were 0.72 and 0.93, respectively. The AUC of the combination of the presence of flow void and Vp was 0.95 and significantly improved compared to that of the presence of flow void (P < 0.001). CONCLUSION Adding DCE-MRI to the head and neck protocol can aid in the precise differentiation between jugular foramen paragangliomas and metastases.
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Affiliation(s)
- Yoshiaki Ota
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA.
| | - Guillaume Curaudeau
- Department of Radiology, The University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH, 43614, USA
| | - Eric Liao
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Jayapalli Bapuraj
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Akira Baba
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Gaurang Shah
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI, 48109, USA
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Ota Y, Liao E, Capizzano AA, Baba A, Kurokawa R, Kurokawa M, Srinivasan A. Differentiation of Skull Base Chondrosarcomas, Chordomas, and Metastases: Utility of DWI and Dynamic Contrast-Enhanced Perfusion MR Imaging. AJNR Am J Neuroradiol 2022; 43:1325-1332. [PMID: 35953276 PMCID: PMC9451640 DOI: 10.3174/ajnr.a7607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Differentiation of skull base tumors, including chondrosarcomas, chordomas, and metastases, on conventional imaging remains a challenge. We aimed to test the utility of DWI and dynamic contrast-enhanced MR imaging for skull base tumors. MATERIALS AND METHODS Fifty-nine patients with chondrosarcomas, chordomas, or metastases between January 2015 and October 2021 were included in this retrospective study. Pretreatment normalized mean ADC and dynamic contrast-enhanced MR imaging parameters were calculated. The Kruskal-Wallis H test for all tumor types and the Mann-Whitney U test for each pair of tumors were used. RESULTS Fifteen chondrosarcomas (9 men; median age, 62 years), 14 chordomas (6 men; median age, 47 years), and 30 metastases (11 men; median age, 61 years) were included in this study. Fractional plasma volume helped distinguish all 3 tumor types (P = .003, <.001, and <.001, respectively), whereas the normalized mean ADC was useful in distinguishing chondrosarcomas from chordomas and metastases (P < .001 and P < .001, respectively); fractional volume of extracellular space, in distinguishing chondrosarcomas from metastases (P = .02); and forward volume transfer constant, in distinguishing metastases from chondrosarcomas/chondroma (P = .002 and .002, respectively) using the Kruskal-Wallis H test. The diagnostic performances of fractional plasma volume for each pair of tumors showed areas under curve of 0.86-0.99 (95% CI, 0.70-1.0); the forward volume transfer constant differentiated metastases from chondrosarcomas/chordomas with areas under curve of 0.82 and 0.82 (95% CI, 0.67-0.98), respectively; and the normalized mean ADC distinguished chondrosarcomas from chordomas/metastases with areas under curve of 0.96 and 0.95 (95% CI, 0.88-1.0), respectively. CONCLUSIONS DWI and dynamic contrast-enhanced MR imaging sequences can be beneficial for differentiating the 3 common skull base tumors.
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Affiliation(s)
- Y Ota
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - E Liao
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A A Capizzano
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A Baba
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiology (A.B.), Jikei University School of Medicine Ringgold standard institution, Tokyo, Japan
| | - R Kurokawa
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiology (R.K.), The University of Tokyo Hospital, Tokyo, Japan
| | - M Kurokawa
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
- Department of Radiology (M.K.), Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital Ringgold standard institution, Bunkyo-ku, Japan
| | - A Srinivasan
- From the Division of Neuroradiology (Y.O., E.L., A.A.C., A.B., R.K., M.K., A.S.), Department of Radiology, University of Michigan, Ann Arbor, Michigan
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Ota Y, Liao E, Capizzano AA, Baba A, Kurokawa R, Kurokawa M, Srinivasan A. Intracranial paragangliomas versus schwannomas: Role of dynamic susceptibility contrast perfusion and diffusion MRI. J Neuroimaging 2022; 32:875-883. [PMID: 35562184 PMCID: PMC9546409 DOI: 10.1111/jon.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/09/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Differentiating paragangliomas from schwannomas and distinguishing sporadic from neurofibromatosis type 2 (NF 2)-related schwannomas is challenging but clinically important. This study aimed to assess the utility of dynamic susceptibility contrast perfusion MRI (DSC-MRI) and diffusion-weighted imaging (DWI) in discriminating infratentorial extra-axial schwannomas from paragangliomas and NF2-related schwannomas. METHODS This retrospective study included 41 patients diagnosed with paragangliomas, sporadic schwannomas, and NF2-related schwannomas in the infratentorial extra-axial space between April 2013 and August 2021. All cases had pretreatment DSC-MRI and DWI. Normalized mean apparent diffusion coefficient (nADCmean), normalized relative cerebral blood volume (nrCBV), and normalized relative cerebral blood flow (nrCBF) were compared between paragangliomas and schwannomas and between sporadic and NF2-related schwannomas as appropriate. RESULTS nrCBV and nrCBF were significantly higher in paragangliomas than in sporadic/NF2-related schwannomas (nrCBV: median 11.5 vs. 1.14/3.74; p < .001 and .004, nrCBF: median 7.43 vs. 1.13/2.85; p < .001 and .007, respectively), while nADCmean were not. The corresponding diagnostic performances were area under the curves (AUCs) of .99/.92 and 1.0/.90 with cutoffs of 2.56/4.22 and 1.94/3.36, respectively. nADCmean were lower, and nrCBV and nrCBF were higher in NF2-related than in sporadic schwannomas (nADCmean: median 1.23 vs. 1.58, nrCBV: median 3.74 vs. 1.14, nrCBF: median 2.85 vs. 1.13; all p < .001), and the corresponding diagnostic performances were AUCs of .93, .91, and .95 with cutoffs of 1.37, 2.63, and 2.48, respectively. CONCLUSIONS DSC-MRI and DWI both can aid in differentiating paragangliomas from schwannomas and sporadic from NF2-related schwannomas.
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Affiliation(s)
- Yoshiaki Ota
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Liao
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Aristides A Capizzano
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Akira Baba
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryo Kurokawa
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mariko Kurokawa
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashok Srinivasan
- Department of Radiology, Division of Neuroradiology, University of Michigan, Ann Arbor, Michigan, USA
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Ota Y, Liao E, Zhao R, Lobo R, Capizzano AA, Bapuraj JR, Shah G, Baba A, Srinivasan A. Advanced MRI to differentiate schwannomas and metastases in the cerebellopontine angle/internal auditory canal. J Neuroimaging 2022; 32:1177-1184. [PMID: 35879866 PMCID: PMC9796724 DOI: 10.1111/jon.13028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/26/2022] [Accepted: 07/11/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND PURPOSE Differentiating schwannomas and metastases in the cerebellopontine angles (CPA)/internal auditory canals (IAC) can be challenging. This study aimed to assess the role of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced MRI (DCE-MRI) to differentiate schwannomas and metastases in the CPA/IAC. METHODS We retrospectively reviewed 368 patients who were diagnosed with schwannomas or metastases in the CPA/IAC between April 2017 and February 2022 in a single academic center. Forty-three patients had pretreatment DWI and DCE-MRI along with conventional MRI. Normalized mean apparent diffusion coefficient ratio (nADCmean) and DCE-MRI parameters of fractional plasma volume (Vp), flux rate constant (Kep), and forward volume transfer constant were compared along with patients' demographics and conventional imaging features between schwannomas and metastases as appropriate. The diagnostic performances and multivariate logistic regression analysis were performed using the significantly different values. RESULTS Between 23 schwannomas (15 males; median 48 years) and 20 metastases (9 males; median 61 years), nADCmean (median: 1.69 vs. 1.43; p = .002), Vp (median: 0.05 vs. 0.20; p < .001), and Kep (median: 0.41 vs. 0.81 minute-1 ; p < .001) were significantly different. The diagnostic performances of nADCmean, Vp, and Kep were 0.77, 0.90, and 0.83 area under the curves, with cutoff values of 1.68, 0.12, and 0.53, respectively. Vp was identified as the most significant parameter for the tumor differentiation in the multivariate logistic regression analysis (p < .001). CONCLUSIONS DWI and DCE-MRI can help differentiate CPA/IAC schwannomas and metastases, and Vp is the most significant parameter.
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Affiliation(s)
- Yoshiaki Ota
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Eric Liao
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Raymond Zhao
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Remy Lobo
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Aristides A. Capizzano
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Jayapalli Rajiv Bapuraj
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Gaurang Shah
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Akira Baba
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of RadiologyUniversity of MichiganAnn ArborMichiganUSA
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