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<meta name="DC.Title" content="Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients" />
<meta name="DC.Identifier" content="10.3174/ajnr.A4500" />
<meta name="DC.Date" content="2016-02-01" />
<meta name="DC.Publisher" content="American Journal of Neuroradiology" />
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<meta name="DC.Description" content="BACKGROUND AND PURPOSE: Outcomes following hematopoietic stem cell transplantation for higher risk childhood-onset cerebral adrenoleukodystrophy are variable. We explored whether a brain MR imaging gadolinium intensity scoring system improves prediction of neurologic outcome.

MATERIALS AND METHODS: We developed a 4-point scale of gadolinium intensity relative to the choroid plexus: 0 = no enhancement; 1 = hypointense; 2 = isointense; 3 = hyperintense. The interobserver concordance of the scale was assessed on 30 randomly chosen studies. Scores were generated for 64 evaluable patients and compared with CSF chitotriosidase levels, a known inflammatory marker correlating with outcomes following transplantation. For 25 evaluable higher risk patients (Loes ≥10), the gadolinium intensity score was compared with longer term posttransplantation clinical change.

RESULTS: The gadolinium intensity scoring system showed good interobserver reproducibility (κ = 0.72). Of 64 evaluable boys, the score positively correlated with average concomitant CSF chitotriosidase activity in nanograms/milliliter/hour: 0: 2717, n = 5; 1: 3218, n = 13; 2: 6497, n = 23; and 3: 12,030, n = 23 ( P &lt; .01). For 25 evaluable higher risk patients, more intense pretransplantation brain MR imaging gadolinium enhancement predicted greater average loss on the adrenoleukodystrophy neurologic function scale following transplantation: 0/1: adrenoleukodystrophy neurologic function scale score difference = 4.3, n = 7; 2/3: adrenoleukodystrophy neurologic function scale score difference = 10.4, n = 18 ( P = .05).

CONCLUSIONS: Gadolinium enhancement intensity on brain MR imaging can be scored simply and reproducibly for cerebral adrenoleukodystrophy. The enhancement score significantly correlates with chitotriosidase. In boys with higher risk cerebral disease (Loes ≥10), the enhancement score itself predicts neurologic outcome following treatment. Such data may help guide treatment decisions for clinicians and families.

ALD
:   adrenoleukodystrophy
cALD
:   cerebral adrenoleukodystrophy
CHIT
:   chitotriosidase
ΔNFS
:   change in NFS score
GIS
:   brain MRI gadolinium intensity scale score
HSCT
:   hematopoietic stem cell transplantation
NFS
:   adrenoleukodystrophy neurologic function scale score" />
<meta name="DC.Contributor" content="W.P. Miller" />
<meta name="DC.Contributor" content="L.F. Mantovani" />
<meta name="DC.Contributor" content="J. Muzic" />
<meta name="DC.Contributor" content="J.B. Rykken" />
<meta name="DC.Contributor" content="R.S. Gawande" />
<meta name="DC.Contributor" content="T.C. Lund" />
<meta name="DC.Contributor" content="R.M. Shanley" />
<meta name="DC.Contributor" content="G.V. Raymond" />
<meta name="DC.Contributor" content="P.J. Orchard" />
<meta name="DC.Contributor" content="D.R. Nascene" />
<meta name="article:published_time" content="2016-02-01" />
<meta name="article:section" content="PEDIATRICS" />
<meta name="citation_title" content="Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients" />
<meta name="citation_abstract" lang="en" content="&lt;h3&gt;BACKGROUND AND PURPOSE:&lt;/h3&gt;
&lt;p&gt;Outcomes following hematopoietic stem cell transplantation for higher risk childhood-onset cerebral adrenoleukodystrophy are variable. We explored whether a brain MR imaging gadolinium intensity scoring system improves prediction of neurologic outcome.&lt;/p&gt;&lt;h3&gt;MATERIALS AND METHODS:&lt;/h3&gt;
&lt;p&gt;We developed a 4-point scale of gadolinium intensity relative to the choroid plexus: 0 = no enhancement; 1 = hypointense; 2 = isointense; 3 = hyperintense. The interobserver concordance of the scale was assessed on 30 randomly chosen studies. Scores were generated for 64 evaluable patients and compared with CSF chitotriosidase levels, a known inflammatory marker correlating with outcomes following transplantation. For 25 evaluable higher risk patients (Loes ≥10), the gadolinium intensity score was compared with longer term posttransplantation clinical change.&lt;/p&gt;&lt;h3&gt;RESULTS:&lt;/h3&gt;
&lt;p&gt;The gadolinium intensity scoring system showed good interobserver reproducibility (κ = 0.72). Of 64 evaluable boys, the score positively correlated with average concomitant CSF chitotriosidase activity in nanograms/milliliter/hour: 0: 2717, &lt;i&gt;n&lt;/i&gt; = 5; 1: 3218, &lt;i&gt;n&lt;/i&gt; = 13; 2: 6497, &lt;i&gt;n&lt;/i&gt; = 23; and 3: 12,030, &lt;i&gt;n&lt;/i&gt; = 23 (&lt;i&gt;P&lt;/i&gt; &amp;lt; .01). For 25 evaluable higher risk patients, more intense pretransplantation brain MR imaging gadolinium enhancement predicted greater average loss on the adrenoleukodystrophy neurologic function scale following transplantation: 0/1: adrenoleukodystrophy neurologic function scale score difference = 4.3, &lt;i&gt;n&lt;/i&gt; = 7; 2/3: adrenoleukodystrophy neurologic function scale score difference = 10.4, &lt;i&gt;n&lt;/i&gt; = 18 (&lt;i&gt;P&lt;/i&gt; = .05).&lt;/p&gt;&lt;h3&gt;CONCLUSIONS:&lt;/h3&gt;
&lt;p&gt;Gadolinium enhancement intensity on brain MR imaging can be scored simply and reproducibly for cerebral adrenoleukodystrophy. The enhancement score significantly correlates with chitotriosidase. In boys with higher risk cerebral disease (Loes ≥10), the enhancement score itself predicts neurologic outcome following treatment. Such data may help guide treatment decisions for clinicians and families.&lt;/p&gt;" />
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<meta name="twitter:title" content="Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients" />
<meta name="twitter:card" content="summary_large_image" />
<meta name="twitter:image" content="http://ajnr-stage2.stage.highwire.org/sites/default/files/highwire/ajnr/37/2.cover-source.jpg" />
<meta name="twitter:description" content="BACKGROUND AND PURPOSE: Outcomes following hematopoietic stem cell transplantation for higher risk childhood-onset cerebral adrenoleukodystrophy are variable. We explored whether a brain MR imaging gadolinium intensity scoring system improves prediction of neurologic outcome.

MATERIALS AND METHODS: We developed a 4-point scale of gadolinium intensity relative to the choroid plexus: 0 = no enhancement; 1 = hypointense; 2 = isointense; 3 = hyperintense. The interobserver concordance of the scale was assessed on 30 randomly chosen studies. Scores were generated for 64 evaluable patients and compared with CSF chitotriosidase levels, a known inflammatory marker correlating with outcomes following transplantation. For 25 evaluable higher risk patients (Loes ≥10), the gadolinium intensity score was compared with longer term posttransplantation clinical change.

RESULTS: The gadolinium intensity scoring system showed good interobserver reproducibility (κ = 0.72). Of 64 evaluable boys, the score positively correlated with average concomitant CSF chitotriosidase activity in nanograms/milliliter/hour: 0: 2717, n = 5; 1: 3218, n = 13; 2: 6497, n = 23; and 3: 12,030, n = 23 ( P &lt; .01). For 25 evaluable higher risk patients, more intense pretransplantation brain MR imaging gadolinium enhancement predicted greater average loss on the adrenoleukodystrophy neurologic function scale following transplantation: 0/1: adrenoleukodystrophy neurologic function scale score difference = 4.3, n = 7; 2/3: adrenoleukodystrophy neurologic function scale score difference = 10.4, n = 18 ( P = .05).

CONCLUSIONS: Gadolinium enhancement intensity on brain MR imaging can be scored simply and reproducibly for cerebral adrenoleukodystrophy. The enhancement score significantly correlates with chitotriosidase. In boys with higher risk cerebral disease (Loes ≥10), the enhancement score itself predicts neurologic outcome following treatment. Such data may help guide treatment decisions for clinicians and families.

ALD
:   adrenoleukodystrophy
cALD
:   cerebral adrenoleukodystrophy
CHIT
:   chitotriosidase
ΔNFS
:   change in NFS score
GIS
:   brain MRI gadolinium intensity scale score
HSCT
:   hematopoietic stem cell transplantation
NFS
:   adrenoleukodystrophy neurologic function scale score" />
<meta name="og-title" property="og:title" content="Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients" />
<meta name="og-url" property="og:url" content="http://ajnr-stage2.stage.highwire.org/content/37/2/367" />
<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: Outcomes following hematopoietic stem cell transplantation for higher risk childhood-onset cerebral adrenoleukodystrophy are variable. We explored whether a brain MR imaging gadolinium intensity scoring system improves prediction of neurologic outcome.

MATERIALS AND METHODS: We developed a 4-point scale of gadolinium intensity relative to the choroid plexus: 0 = no enhancement; 1 = hypointense; 2 = isointense; 3 = hyperintense. The interobserver concordance of the scale was assessed on 30 randomly chosen studies. Scores were generated for 64 evaluable patients and compared with CSF chitotriosidase levels, a known inflammatory marker correlating with outcomes following transplantation. For 25 evaluable higher risk patients (Loes ≥10), the gadolinium intensity score was compared with longer term posttransplantation clinical change.

RESULTS: The gadolinium intensity scoring system showed good interobserver reproducibility (κ = 0.72). Of 64 evaluable boys, the score positively correlated with average concomitant CSF chitotriosidase activity in nanograms/milliliter/hour: 0: 2717, n = 5; 1: 3218, n = 13; 2: 6497, n = 23; and 3: 12,030, n = 23 ( P &lt; .01). For 25 evaluable higher risk patients, more intense pretransplantation brain MR imaging gadolinium enhancement predicted greater average loss on the adrenoleukodystrophy neurologic function scale following transplantation: 0/1: adrenoleukodystrophy neurologic function scale score difference = 4.3, n = 7; 2/3: adrenoleukodystrophy neurologic function scale score difference = 10.4, n = 18 ( P = .05).

CONCLUSIONS: Gadolinium enhancement intensity on brain MR imaging can be scored simply and reproducibly for cerebral adrenoleukodystrophy. The enhancement score significantly correlates with chitotriosidase. In boys with higher risk cerebral disease (Loes ≥10), the enhancement score itself predicts neurologic outcome following treatment. Such data may help guide treatment decisions for clinicians and families.

ALD
:   adrenoleukodystrophy
cALD
:   cerebral adrenoleukodystrophy
CHIT
:   chitotriosidase
ΔNFS
:   change in NFS score
GIS
:   brain MRI gadolinium intensity scale score
HSCT
:   hematopoietic stem cell transplantation
NFS
:   adrenoleukodystrophy neurologic function scale score" />
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    <title>Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients | American Journal of Neuroradiology</title>  
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      <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></div>
  
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      <h1 class="highwire-cite-title" id="page-title">Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">W.P. Miller</span>, <span class="highwire-citation-author" data-delta="1">L.F. Mantovani</span>, <span class="highwire-citation-author" data-delta="2">J. Muzic</span>, <span class="highwire-citation-author" data-delta="3">J.B. Rykken</span>, <span class="highwire-citation-author" data-delta="4">R.S. Gawande</span>, <span class="highwire-citation-author" data-delta="5">T.C. Lund</span>, <span class="highwire-citation-author" data-delta="6">R.M. Shanley</span>, <span class="highwire-citation-author" data-delta="7">G.V. Raymond</span>, <span class="highwire-citation-author" data-delta="8">P.J. Orchard</span> and <span class="highwire-citation-author" data-delta="9">D.R. Nascene</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">February 2016,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">37 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">367-372; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A4500 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-14256--61804097289" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">W.P. Miller </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Division of Pediatric Blood and Marrow Transplant (W.P.M., T.C.L., P.J.O.), Department of Pediatrics</div></span></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=W.P.%2BMiller%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=Miller%20W&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"><a href="/search/author1%3AW.P.%2BMiller%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0003-3168-3337" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for W.P. Miller</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">L.F. Mantovani </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>d</span>Division of Hematology and Oncology (L.F.M.), Department of Pediatrics, University of Sao Paulo, Sao Paulo, Brazil</div></span></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=L.F.%2BMantovani%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=Mantovani%20L&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"><a href="/search/author1%3AL.F.%2BMantovani%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-2623-461X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for L.F. Mantovani</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">J. Muzic </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>e</span>University of Minnesota Medical School (J.M.), Minneapolis, Minnesota</div></span></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.%2BMuzic%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=Muzic%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"><a href="/search/author1%3AJ.%2BMuzic%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0001-8457-5925" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J. Muzic</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">J.B. Rykken </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Departments of Diagnostic Radiology (J.B.R., R.S.G., D.R.N.)</div></span></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.B.%2BRykken%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=Rykken%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"><a href="/search/author1%3AJ.B.%2BRykken%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0002-1958-2448" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J.B. 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Gawande </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Departments of Diagnostic Radiology (J.B.R., R.S.G., D.R.N.)</div></span></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=R.S.%2BGawande%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=Gawande%20R&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"><a href="/search/author1%3AR.S.%2BGawande%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0003-2976-1519" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for R.S. Gawande</a></li></ul></div><div class="author-tooltip-5"><div class="author-tooltip-name">T.C. Lund </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Division of Pediatric Blood and Marrow Transplant (W.P.M., T.C.L., P.J.O.), Department of Pediatrics</div></span></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=T.C.%2BLund%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=Lund%20T&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"><a href="/search/author1%3AT.C.%2BLund%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0001-9174-8919" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for T.C. Lund</a></li></ul></div><div class="author-tooltip-6"><div class="author-tooltip-name">R.M. Shanley </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>f</span>Biostatistics Core (R.M.S.), Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota.</div></span></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=R.M.%2BShanley%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=Shanley%20R&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"><a href="/search/author1%3AR.M.%2BShanley%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="http://orcid.org/0000-0003-2398-5466" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for R.M. 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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 37</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 2 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Feb 2016 </div></div>
      
      
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      <div class="highwire-cite-title">Intensity of MRI Gadolinium Enhancement in Cerebral Adrenoleukodystrophy: A Biomarker for Inflammation and Predictor of Outcome following Transplantation in Higher Risk Patients</div>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">W.P.</span> <span class="nlm-surname">Miller</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">L.F.</span> <span class="nlm-surname">Mantovani</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">J.</span> <span class="nlm-surname">Muzic</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">J.B.</span> <span class="nlm-surname">Rykken</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">R.S.</span> <span class="nlm-surname">Gawande</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">T.C.</span> <span class="nlm-surname">Lund</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">R.M.</span> <span class="nlm-surname">Shanley</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">G.V.</span> <span class="nlm-surname">Raymond</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">P.J.</span> <span class="nlm-surname">Orchard</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">D.R.</span> <span class="nlm-surname">Nascene</span></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">Feb 2016, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">37 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">367-372; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A4500 </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">W.P.</span> <span class="nlm-surname">Miller</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">L.F.</span> <span class="nlm-surname">Mantovani</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">J.</span> <span class="nlm-surname">Muzic</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">J.B.</span> <span class="nlm-surname">Rykken</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">R.S.</span> <span class="nlm-surname">Gawande</span></span>, <span class="highwire-citation-author" data-delta="5"><span class="nlm-given-names">T.C.</span> <span class="nlm-surname">Lund</span></span>, <span class="highwire-citation-author" data-delta="6"><span class="nlm-given-names">R.M.</span> <span class="nlm-surname">Shanley</span></span>, <span class="highwire-citation-author" data-delta="7"><span class="nlm-given-names">G.V.</span> <span class="nlm-surname">Raymond</span></span>, <span class="highwire-citation-author" data-delta="8"><span class="nlm-given-names">P.J.</span> <span class="nlm-surname">Orchard</span></span>, <span class="highwire-citation-author" data-delta="9"><span class="nlm-given-names">D.R.</span> <span class="nlm-surname">Nascene</span></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">Feb 2016, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">37 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(2) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">367-372; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A4500 </span></div>
  
  
  
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