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<meta name="DC.Title" content="Clinical and Radiological Features of Rotavirus Cerebellitis" />
<meta name="DC.Identifier" content="10.3174/ajnr.A2131" />
<meta name="DC.Date" content="2010-10-01" />
<meta name="DC.Publisher" content="American Journal of Neuroradiology" />
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Indicates open access to non-subscribers at www.ajnr.org" />
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<meta name="DC.Description" content="BACKGROUND AND PURPOSE: Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.

MATERIALS AND METHODS: Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.

RESULTS: A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.

CONCLUSIONS: The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.

A
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AESD
:   acute encephalopathy with biphasic seizures and late reduced diffusion
ANE
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C
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CC
:   corpus callosum
CNS
:   central nervous system
D
:   day
Dy
:   dysarthria
EEG
:   electroencephalogram
FLAIR
:   fluid-attenuated inversion recovery
G
:   gray matter
H
:   hypotonia
MeR
:   mental retardation
MERS
:   clinically mild encephalitis/encephalopathy with a reversible splenial lesion
Mu
:   mutism
Ny
:   nystagmus
N
:   cerebellar nucleus
PCR
:   polymerase chain reaction
Pt
:   patient
S
:   seizures
T
:   tremor
V
:   vermis
W
:   white matter" />
<meta name="DC.Contributor" content="J. Takanashi" />
<meta name="DC.Contributor" content="T. Miyamoto" />
<meta name="DC.Contributor" content="N. Ando" />
<meta name="DC.Contributor" content="T. Kubota" />
<meta name="DC.Contributor" content="M. Oka" />
<meta name="DC.Contributor" content="Z. Kato" />
<meta name="DC.Contributor" content="S. Hamano" />
<meta name="DC.Contributor" content="S. Hirabayashi" />
<meta name="DC.Contributor" content="M. Kikuchi" />
<meta name="DC.Contributor" content="A.J. Barkovich" />
<meta name="article:published_time" content="2010-10-01" />
<meta name="article:section" content="Pediatrics" />
<meta name="citation_title" content="Clinical and Radiological Features of Rotavirus Cerebellitis" />
<meta name="citation_abstract" lang="en" content="&lt;h3&gt;BACKGROUND AND PURPOSE:&lt;/h3&gt;
&lt;p&gt;Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.&lt;/p&gt;&lt;h3&gt;MATERIALS AND METHODS:&lt;/h3&gt;
&lt;p&gt;Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.&lt;/p&gt;&lt;h3&gt;RESULTS:&lt;/h3&gt;
&lt;p&gt;A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.&lt;/p&gt;&lt;h3&gt;CONCLUSIONS:&lt;/h3&gt;
&lt;p&gt;The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.&lt;/p&gt;" />
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<meta name="citation_publication_date" content="2010/10/01" />
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<meta name="citation_firstpage" content="1591" />
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<meta name="citation_author" content="J. Takanashi" />
<meta name="citation_author" content="T. Miyamoto" />
<meta name="citation_author" content="N. Ando" />
<meta name="citation_author" content="T. Kubota" />
<meta name="citation_author" content="M. Oka" />
<meta name="citation_author" content="Z. Kato" />
<meta name="citation_author" content="S. Hamano" />
<meta name="citation_author" content="S. Hirabayashi" />
<meta name="citation_author" content="M. Kikuchi" />
<meta name="citation_author" content="A.J. Barkovich" />
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<meta name="twitter:title" content="Clinical and Radiological Features of Rotavirus Cerebellitis" />
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<meta name="twitter:description" content="BACKGROUND AND PURPOSE: Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.

MATERIALS AND METHODS: Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.

RESULTS: A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.

CONCLUSIONS: The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.

A
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AESD
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ANE
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C
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CC
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CNS
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D
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Dy
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EEG
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FLAIR
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G
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H
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MeR
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MERS
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Mu
:   mutism
Ny
:   nystagmus
N
:   cerebellar nucleus
PCR
:   polymerase chain reaction
Pt
:   patient
S
:   seizures
T
:   tremor
V
:   vermis
W
:   white matter" />
<meta name="og-title" property="og:title" content="Clinical and Radiological Features of Rotavirus Cerebellitis" />
<meta name="og-url" property="og:url" content="http://ajnr-stage2.stage.highwire.org/content/31/9/1591" />
<meta name="og-site-name" property="og:site_name" content="American Journal of Neuroradiology" />
<meta name="og-description" property="og:description" content="BACKGROUND AND PURPOSE: Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.

MATERIALS AND METHODS: Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.

RESULTS: A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.

CONCLUSIONS: The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.

A
:   ataxia
AESD
:   acute encephalopathy with biphasic seizures and late reduced diffusion
ANE
:   acute necrotizing encephalopathy
C
:   consciousness disturbance
CC
:   corpus callosum
CNS
:   central nervous system
D
:   day
Dy
:   dysarthria
EEG
:   electroencephalogram
FLAIR
:   fluid-attenuated inversion recovery
G
:   gray matter
H
:   hypotonia
MeR
:   mental retardation
MERS
:   clinically mild encephalitis/encephalopathy with a reversible splenial lesion
Mu
:   mutism
Ny
:   nystagmus
N
:   cerebellar nucleus
PCR
:   polymerase chain reaction
Pt
:   patient
S
:   seizures
T
:   tremor
V
:   vermis
W
:   white matter" />
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    <div class="highwire-article-citation highwire-citation-type-highwire-article node9844--5" data-node-nid="9844" id="top-node-9844--6130861754" data-pisa="ajnr;31/9/1591" data-pisa-master="ajnr;ajnr.A2131" data-apath="/ajnr/31/9/1591.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
      <div class="highwire-cite-overline"><span  class="highwire-cite-metadata-article-type highwire-cite-metadata">Research Article</span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-cat highwire-cite-metadata"><span class="wrapper">Pediatrics</span></span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-series highwire-cite-metadata">F</span></div>
  
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      <h1 class="highwire-cite-title" id="page-title">Clinical and Radiological Features of Rotavirus Cerebellitis</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">J. Takanashi</span>, <span class="highwire-citation-author" data-delta="1">T. Miyamoto</span>, <span class="highwire-citation-author" data-delta="2">N. Ando</span>, <span class="highwire-citation-author" data-delta="3">T. Kubota</span>, <span class="highwire-citation-author" data-delta="4">M. Oka</span>, <span class="highwire-citation-author" data-delta="5">Z. Kato</span>, <span class="highwire-citation-author" data-delta="6">S. Hamano</span>, <span class="highwire-citation-author" data-delta="7">S. Hirabayashi</span>, <span class="highwire-citation-author" data-delta="8">M. Kikuchi</span> and <span class="highwire-citation-author" data-delta="9">A.J. Barkovich</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">October 2010,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">31 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">1591-1595; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A2131 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-9844--6130861754" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">J. Takanashi </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.%2BTakanashi%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Takanashi%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AJ.%2BTakanashi%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">T. 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<p id="p-4"><strong>BACKGROUND AND PURPOSE:</strong> Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.</p>
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<p id="p-5"><strong>MATERIALS AND METHODS:</strong> Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.</p>
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<p id="p-6"><strong>RESULTS:</strong> A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.</p>
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<p id="p-7"><strong>CONCLUSIONS:</strong> The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.</p>
</div></div><div class="section glossary" id="glossary-1"><h2>Abbreviations</h2><dl id="def-list-1"><dt id="def-item-1">A<span class="def-item-dt-sep"></span></dt><dd>ataxia<span class="def-item-dd-sep"></span></dd><dt id="def-item-2">AESD<span class="def-item-dt-sep"></span></dt><dd>acute encephalopathy with biphasic seizures and late reduced diffusion<span class="def-item-dd-sep"></span></dd><dt id="def-item-3">ANE<span class="def-item-dt-sep"></span></dt><dd>acute necrotizing encephalopathy<span class="def-item-dd-sep"></span></dd><dt id="def-item-4">C<span class="def-item-dt-sep"></span></dt><dd>consciousness disturbance<span class="def-item-dd-sep"></span></dd><dt id="def-item-5">CC<span class="def-item-dt-sep"></span></dt><dd>corpus callosum<span class="def-item-dd-sep"></span></dd><dt id="def-item-6">CNS<span class="def-item-dt-sep"></span></dt><dd>central nervous system<span class="def-item-dd-sep"></span></dd><dt id="def-item-7">D<span class="def-item-dt-sep"></span></dt><dd>day<span class="def-item-dd-sep"></span></dd><dt id="def-item-8">Dy<span class="def-item-dt-sep"></span></dt><dd>dysarthria<span class="def-item-dd-sep"></span></dd><dt id="def-item-9">EEG<span class="def-item-dt-sep"></span></dt><dd>electroencephalogram<span class="def-item-dd-sep"></span></dd><dt id="def-item-10">FLAIR<span class="def-item-dt-sep"></span></dt><dd>fluid-attenuated inversion recovery<span class="def-item-dd-sep"></span></dd><dt id="def-item-11">G<span class="def-item-dt-sep"></span></dt><dd>gray matter<span class="def-item-dd-sep"></span></dd><dt id="def-item-12">H<span class="def-item-dt-sep"></span></dt><dd>hypotonia<span class="def-item-dd-sep"></span></dd><dt id="def-item-13">MeR<span class="def-item-dt-sep"></span></dt><dd>mental retardation<span class="def-item-dd-sep"></span></dd><dt id="def-item-14">MERS<span class="def-item-dt-sep"></span></dt><dd>clinically mild encephalitis/encephalopathy with a reversible splenial lesion<span class="def-item-dd-sep"></span></dd><dt id="def-item-15">Mu<span class="def-item-dt-sep"></span></dt><dd>mutism<span class="def-item-dd-sep"></span></dd><dt id="def-item-16">Ny<span class="def-item-dt-sep"></span></dt><dd>nystagmus<span class="def-item-dd-sep"></span></dd><dt id="def-item-17">N<span class="def-item-dt-sep"></span></dt><dd>cerebellar nucleus<span class="def-item-dd-sep"></span></dd><dt id="def-item-18">PCR<span class="def-item-dt-sep"></span></dt><dd>polymerase chain reaction<span class="def-item-dd-sep"></span></dd><dt id="def-item-19">Pt<span class="def-item-dt-sep"></span></dt><dd>patient<span class="def-item-dd-sep"></span></dd><dt id="def-item-20">S<span class="def-item-dt-sep"></span></dt><dd>seizures<span class="def-item-dd-sep"></span></dd><dt id="def-item-21">T<span class="def-item-dt-sep"></span></dt><dd>tremor<span class="def-item-dd-sep"></span></dd><dt id="def-item-22">V<span class="def-item-dt-sep"></span></dt><dd>vermis<span class="def-item-dd-sep"></span></dd><dt id="def-item-23">W<span class="def-item-dt-sep"></span></dt><dd>white matter</dd></dl></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">Copyright © American Society of Neuroradiology</li></ul><div class="license" id="license-1"><p id="p-3">Indicates open access to non-subscribers at <a href="http://www.ajnr.org">www.ajnr.org</a></p></div><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div><a href="http://ajnr-stage2.stage.highwire.org/content/31/9/1591.full" class="hw-link hw-link-article-full-text" data-icon-position="" data-hide-link-title="0">View Full Text</a></div>  </div>

  
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">J.</span> <span class="nlm-surname">Takanashi</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">T.</span> <span class="nlm-surname">Miyamoto</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">N.</span> <span class="nlm-surname">Ando</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">T.</span> <span class="nlm-surname">Kubota</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">M.</span> <span class="nlm-surname">Oka</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">Z.</span> <span class="nlm-surname">Kato</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Hamano</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Hirabayashi</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">M.</span> <span class="nlm-surname">Kikuchi</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">A.J.</span> <span class="nlm-surname">Barkovich</span></span></span></div>
  
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">J.</span> <span class="nlm-surname">Takanashi</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">T.</span> <span class="nlm-surname">Miyamoto</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">N.</span> <span class="nlm-surname">Ando</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">T.</span> <span class="nlm-surname">Kubota</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">M.</span> <span class="nlm-surname">Oka</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">Z.</span> <span class="nlm-surname">Kato</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Hamano</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Hirabayashi</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">M.</span> <span class="nlm-surname">Kikuchi</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">A.J.</span> <span class="nlm-surname">Barkovich</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-oa-ind highwire-cite-metadata"><i class="highwire-oa-indicator"></i> </span><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Oct 2010, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">31 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(9) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">1591-1595; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A2131 </span></div>
  
  
  
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