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<meta name="DC.Title" content="Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis" />
<meta name="DC.Identifier" content="10.3174/ajnr.A5541" />
<meta name="DC.Date" content="2018-04-01" />
<meta name="DC.Publisher" content="American Journal of Neuroradiology" />
<meta name="DC.Rights" content="© 2018 by American Journal of Neuroradiology" />
<meta name="DC.AccessRights" content="restricted" />
<meta name="DC.Description" content="BACKGROUND AND PURPOSE: Leptomeningeal contrast enhancement is found in patients with multiple sclerosis, though reported rates have varied. The use of 3D-fluid-attenuated inversion recovery pre- and postcontrast subtraction imaging may more accurately determine the frequency of leptomeningeal contrast enhancement. The purpose of this study was to investigate the frequency of leptomeningeal contrast enhancement using the pre- and postcontrast subtraction approach and to evaluate 3 different methods of assessing the presence of leptomeningeal contrast enhancement.

MATERIALS AND METHODS: We enrolled 258 consecutive patients with MS (212 with relapsing-remitting MS, 32 with secondary-progressive MS, and 14 with clinically isolated syndrome) who underwent both pre- and 10-minute postcontrast 3D-FLAIR sequences after a single dose of gadolinium injection on 3T MR imaging. The analysis included leptomeningeal contrast-enhancement evaluation on 3D-FLAIR postcontrast images in native space (method A), on pre- and postcontrast 3D-FLAIR images in native space (method B), and on pre-/postcontrast 3D-FLAIR coregistered and subtracted images (method C, used as the criterion standard).

RESULTS: In total, 51 (19.7%) patients with MS showed the presence of leptomeningeal contrast enhancement using method A; 39 (15.1%), using method B; and 39 (15.1%), using method C ( P = .002). Compared with method C as the criterion standard, method A showed 89.8% sensitivity and 92.7% specificity, while method B showed 84.6% sensitivity and 97.3% specificity ( P &lt; .001) at the patient level. Reproducibility was the highest using method C (κ agreement, r = 088, P &lt; .001). The mean time to analyze the 3D-FLAIR images was significantly lower with method C compared with methods A and B ( P &lt; .001).

CONCLUSIONS: 3D-FLAIR postcontrast imaging offers a sensitive method for detecting leptomeningeal contrast enhancement in patients with MS. However, the use of subtraction imaging helped avoid false-positive cases, decreased reading time, and increased the accuracy of leptomeningeal contrast-enhancement foci detection in a clinical routine.

CE
:   contrast enhancement
CIS
:   clinically isolated syndrome
Gd
:   gadolinium
LM
:   leptomeningeal
LV
:   lesion volume
NPV
:   negative predictive value
PPV
:   positive predictive value
RR
:   relapsing-remitting
SP
:   secondary-progressive" />
<meta name="DC.Contributor" content="R. Zivadinov" />
<meta name="DC.Contributor" content="D.P. Ramasamy" />
<meta name="DC.Contributor" content="J. Hagemeier" />
<meta name="DC.Contributor" content="C. Kolb" />
<meta name="DC.Contributor" content="N. Bergsland" />
<meta name="DC.Contributor" content="F. Schweser" />
<meta name="DC.Contributor" content="M.G. Dwyer" />
<meta name="DC.Contributor" content="B. Weinstock-Guttman" />
<meta name="DC.Contributor" content="D. Hojnacki" />
<meta name="article:published_time" content="2018-04-01" />
<meta name="article:section" content="ADULT BRAIN" />
<meta name="citation_title" content="Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis" />
<meta name="citation_abstract" lang="en" content="&lt;h3&gt;BACKGROUND AND PURPOSE:&lt;/h3&gt;
&lt;p&gt;Leptomeningeal contrast enhancement is found in patients with multiple sclerosis, though reported rates have varied. The use of 3D-fluid-attenuated inversion recovery pre- and postcontrast subtraction imaging may more accurately determine the frequency of leptomeningeal contrast enhancement. The purpose of this study was to investigate the frequency of leptomeningeal contrast enhancement using the pre- and postcontrast subtraction approach and to evaluate 3 different methods of assessing the presence of leptomeningeal contrast enhancement.&lt;/p&gt;&lt;h3&gt;MATERIALS AND METHODS:&lt;/h3&gt;
&lt;p&gt;We enrolled 258 consecutive patients with MS (212 with relapsing-remitting MS, 32 with secondary-progressive MS, and 14 with clinically isolated syndrome) who underwent both pre- and 10-minute postcontrast 3D-FLAIR sequences after a single dose of gadolinium injection on 3T MR imaging. The analysis included leptomeningeal contrast-enhancement evaluation on 3D-FLAIR postcontrast images in native space (method A), on pre- and postcontrast 3D-FLAIR images in native space (method B), and on pre-/postcontrast 3D-FLAIR coregistered and subtracted images (method C, used as the criterion standard).&lt;/p&gt;&lt;h3&gt;RESULTS:&lt;/h3&gt;
&lt;p&gt;In total, 51 (19.7%) patients with MS showed the presence of leptomeningeal contrast enhancement using method A; 39 (15.1%), using method B; and 39 (15.1%), using method C (&lt;i&gt;P&lt;/i&gt; = .002). Compared with method C as the criterion standard, method A showed 89.8% sensitivity and 92.7% specificity, while method B showed 84.6% sensitivity and 97.3% specificity (&lt;i&gt;P&lt;/i&gt; &amp;lt; .001) at the patient level. Reproducibility was the highest using method C (κ agreement, &lt;i&gt;r&lt;/i&gt; = 088, &lt;i&gt;P&lt;/i&gt; &amp;lt; .001). The mean time to analyze the 3D-FLAIR images was significantly lower with method C compared with methods A and B (&lt;i&gt;P&lt;/i&gt; &amp;lt; .001).&lt;/p&gt;&lt;h3&gt;CONCLUSIONS:&lt;/h3&gt;
&lt;p&gt;3D-FLAIR postcontrast imaging offers a sensitive method for detecting leptomeningeal contrast enhancement in patients with MS. However, the use of subtraction imaging helped avoid false-positive cases, decreased reading time, and increased the accuracy of leptomeningeal contrast-enhancement foci detection in a clinical routine.&lt;/p&gt;" />
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<meta name="twitter:title" content="Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis" />
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<meta name="twitter:description" content="BACKGROUND AND PURPOSE: Leptomeningeal contrast enhancement is found in patients with multiple sclerosis, though reported rates have varied. The use of 3D-fluid-attenuated inversion recovery pre- and postcontrast subtraction imaging may more accurately determine the frequency of leptomeningeal contrast enhancement. The purpose of this study was to investigate the frequency of leptomeningeal contrast enhancement using the pre- and postcontrast subtraction approach and to evaluate 3 different methods of assessing the presence of leptomeningeal contrast enhancement.

MATERIALS AND METHODS: We enrolled 258 consecutive patients with MS (212 with relapsing-remitting MS, 32 with secondary-progressive MS, and 14 with clinically isolated syndrome) who underwent both pre- and 10-minute postcontrast 3D-FLAIR sequences after a single dose of gadolinium injection on 3T MR imaging. The analysis included leptomeningeal contrast-enhancement evaluation on 3D-FLAIR postcontrast images in native space (method A), on pre- and postcontrast 3D-FLAIR images in native space (method B), and on pre-/postcontrast 3D-FLAIR coregistered and subtracted images (method C, used as the criterion standard).

RESULTS: In total, 51 (19.7%) patients with MS showed the presence of leptomeningeal contrast enhancement using method A; 39 (15.1%), using method B; and 39 (15.1%), using method C ( P = .002). Compared with method C as the criterion standard, method A showed 89.8% sensitivity and 92.7% specificity, while method B showed 84.6% sensitivity and 97.3% specificity ( P &lt; .001) at the patient level. Reproducibility was the highest using method C (κ agreement, r = 088, P &lt; .001). The mean time to analyze the 3D-FLAIR images was significantly lower with method C compared with methods A and B ( P &lt; .001).

CONCLUSIONS: 3D-FLAIR postcontrast imaging offers a sensitive method for detecting leptomeningeal contrast enhancement in patients with MS. However, the use of subtraction imaging helped avoid false-positive cases, decreased reading time, and increased the accuracy of leptomeningeal contrast-enhancement foci detection in a clinical routine.

CE
:   contrast enhancement
CIS
:   clinically isolated syndrome
Gd
:   gadolinium
LM
:   leptomeningeal
LV
:   lesion volume
NPV
:   negative predictive value
PPV
:   positive predictive value
RR
:   relapsing-remitting
SP
:   secondary-progressive" />
<meta name="og-title" property="og:title" content="Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis" />
<meta name="og-url" property="og:url" content="http://ajnr-stage2.stage.highwire.org/content/39/4/642" />
<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: Leptomeningeal contrast enhancement is found in patients with multiple sclerosis, though reported rates have varied. The use of 3D-fluid-attenuated inversion recovery pre- and postcontrast subtraction imaging may more accurately determine the frequency of leptomeningeal contrast enhancement. The purpose of this study was to investigate the frequency of leptomeningeal contrast enhancement using the pre- and postcontrast subtraction approach and to evaluate 3 different methods of assessing the presence of leptomeningeal contrast enhancement.

MATERIALS AND METHODS: We enrolled 258 consecutive patients with MS (212 with relapsing-remitting MS, 32 with secondary-progressive MS, and 14 with clinically isolated syndrome) who underwent both pre- and 10-minute postcontrast 3D-FLAIR sequences after a single dose of gadolinium injection on 3T MR imaging. The analysis included leptomeningeal contrast-enhancement evaluation on 3D-FLAIR postcontrast images in native space (method A), on pre- and postcontrast 3D-FLAIR images in native space (method B), and on pre-/postcontrast 3D-FLAIR coregistered and subtracted images (method C, used as the criterion standard).

RESULTS: In total, 51 (19.7%) patients with MS showed the presence of leptomeningeal contrast enhancement using method A; 39 (15.1%), using method B; and 39 (15.1%), using method C ( P = .002). Compared with method C as the criterion standard, method A showed 89.8% sensitivity and 92.7% specificity, while method B showed 84.6% sensitivity and 97.3% specificity ( P &lt; .001) at the patient level. Reproducibility was the highest using method C (κ agreement, r = 088, P &lt; .001). The mean time to analyze the 3D-FLAIR images was significantly lower with method C compared with methods A and B ( P &lt; .001).

CONCLUSIONS: 3D-FLAIR postcontrast imaging offers a sensitive method for detecting leptomeningeal contrast enhancement in patients with MS. However, the use of subtraction imaging helped avoid false-positive cases, decreased reading time, and increased the accuracy of leptomeningeal contrast-enhancement foci detection in a clinical routine.

CE
:   contrast enhancement
CIS
:   clinically isolated syndrome
Gd
:   gadolinium
LM
:   leptomeningeal
LV
:   lesion volume
NPV
:   negative predictive value
PPV
:   positive predictive value
RR
:   relapsing-remitting
SP
:   secondary-progressive" />
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    <div class="highwire-article-citation highwire-citation-type-highwire-article node60171--5" data-node-nid="60171" id="top-node-60171--6977639471" data-pisa="ajnr;39/4/642" data-pisa-master="ajnr;ajnr.A5541" data-apath="/ajnr/39/4/642.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">ADULT BRAIN</span></span></div>
  
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      <h1 class="highwire-cite-title" id="page-title">Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">R. Zivadinov</span>, <span class="highwire-citation-author" data-delta="1">D.P. Ramasamy</span>, <span class="highwire-citation-author" data-delta="2">J. Hagemeier</span>, <span class="highwire-citation-author" data-delta="3">C. Kolb</span>, <span class="highwire-citation-author" data-delta="4">N. Bergsland</span>, <span class="highwire-citation-author" data-delta="5">F. Schweser</span>, <span class="highwire-citation-author" data-delta="6">M.G. Dwyer</span>, <span class="highwire-citation-author" data-delta="7">B. Weinstock-Guttman</span> and <span class="highwire-citation-author" data-delta="8">D. Hojnacki</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">April 2018,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">642-647; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A5541 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-60171--6977639471" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">R. Zivadinov </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</div><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Neurology (R.Z., C.K., D.H.), Jacobs Comprehensive MS Treatment and Research Center, University at Buffalo, State University of New York, Buffalo, New York.</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.%2BZivadinov%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=Zivadinov%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.%2BZivadinov%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="https://orcid.org/0000-0002-7799-1485" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for R. Zivadinov</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">D.P. Ramasamy </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</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=D.P.%2BRamasamy%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=Ramasamy%20D&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%3AD.P.%2BRamasamy%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="https://orcid.org/0000-0003-0691-5087" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for D.P. Ramasamy</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">J. Hagemeier </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</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.%2BHagemeier%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=Hagemeier%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.%2BHagemeier%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="https://orcid.org/0000-0002-3286-5207" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J. Hagemeier</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">C. Kolb </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Neurology (R.Z., C.K., D.H.), Jacobs Comprehensive MS Treatment and Research Center, University at Buffalo, State University of New York, Buffalo, New York.</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=C.%2BKolb%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=Kolb%20C&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%3AC.%2BKolb%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="https://orcid.org/0000-0001-7761-2548" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for C. Kolb</a></li></ul></div><div class="author-tooltip-4"><div class="author-tooltip-name">N. Bergsland </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</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=N.%2BBergsland%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=Bergsland%20N&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%3AN.%2BBergsland%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="https://orcid.org/0000-0002-7792-0433" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for N. Bergsland</a></li></ul></div><div class="author-tooltip-5"><div class="author-tooltip-name">F. Schweser </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</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=F.%2BSchweser%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=Schweser%20F&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%3AF.%2BSchweser%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="https://orcid.org/0000-0003-0399-9211" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for F. Schweser</a></li></ul></div><div class="author-tooltip-6"><div class="author-tooltip-name">M.G. Dwyer </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>From the Department of Neurology (R.Z., D.P.R., J.H., N.B., F.S., M.G.D.), Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences</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=M.G.%2BDwyer%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=Dwyer%20M&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%3AM.G.%2BDwyer%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="https://orcid.org/0000-0003-4684-4658" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for M.G. Dwyer</a></li></ul></div><div class="author-tooltip-7"><div class="author-tooltip-name">B. Weinstock-Guttman </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>b</span>Translational Imaging Center at Clinical Translational Science Institute (B.W.-G.)</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=B.%2BWeinstock-Guttman%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=Weinstock-Guttman%20B&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%3AB.%2BWeinstock-Guttman%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="https://orcid.org/0000-0001-6732-151X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for B. Weinstock-Guttman</a></li></ul></div><div class="author-tooltip-8"><div class="author-tooltip-name">D. Hojnacki </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Department of Neurology (R.Z., C.K., D.H.), Jacobs Comprehensive MS Treatment and Research Center, University at Buffalo, State University of New York, Buffalo, New York.</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=D.%2BHojnacki%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=Hojnacki%20D&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%3AD.%2BHojnacki%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="https://orcid.org/0000-0002-2518-848X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for D. Hojnacki</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" xmlns:xhtml="http://www.w3.org/1999/xhtml" class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-39.4.642.1" data-doi="10.1186/1471-2377-12-11"><div class="cit-metadata"><ol class="cit-auth-list"><li>
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</li><li><span class="cit-auth"><span class="cit-name-surname">Magliozzi</span>  <span class="cit-name-given-names">R</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Howell</span>  <span class="cit-name-given-names">OW</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Reeves</span>  <span class="cit-name-given-names">C</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">A gradient of neuronal loss and meningeal inflammation in multiple sclerosis</span>. <abbr class="cit-jnl-abbrev">Ann Neurol</abbr> <span class="cit-pub-date">2010</span>;<span class="cit-vol">68</span>:<span class="cit-fpage">477</span>–<span class="cit-lpage">93</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1002/ana.22230</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>20976767</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1002/ana.22230&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=20976767&amp;link_type=MED&amp;atom=%2Fajnr%2F39%2F4%2F642.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a><a href="/lookup/external-ref?access_num=000283398600009&amp;link_type=ISI" class="cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience"><span>Web of Science</span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a><div class="cit ref-cit ref-journal" id="cit-39.4.642.4" data-doi="10.1111/j.1750-3639.2004.tb00049.x"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Serafini</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Rosicarelli</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Magliozzi</span>  <span class="cit-name-given-names">R</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Detection of ectopic B-cell follicles with germinal centers in the meninges of patients with secondary progressive multiple sclerosis</span>. <abbr class="cit-jnl-abbrev">Brain Pathol</abbr> <span class="cit-pub-date">2004</span>;<span class="cit-vol">14</span>:<span class="cit-fpage">164</span>–<span class="cit-lpage">74</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1111/j.1750-3639.2004.tb00049.x</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>15193029</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1111/j.1750-3639.2004.tb00049.x&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=15193029&amp;link_type=MED&amp;atom=%2Fajnr%2F39%2F4%2F642.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a><a href="/lookup/external-ref?access_num=000221410900006&amp;link_type=ISI" class="cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience"><span>Web of Science</span></a></div></div></li><li><span class="ref-label">5.</span><a class="rev-xref-ref" href="#xref-ref-5-1" title="View reference 5. in text" id="ref-5">↵</a><div class="cit ref-cit ref-journal" id="cit-39.4.642.5" data-doi="10.1056/NEJMoa1100648"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Lucchinetti</span>  <span class="cit-name-given-names">CF</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Popescu</span>  <span class="cit-name-given-names">BF</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Bunyan</span>  <span class="cit-name-given-names">RF</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Inflammatory cortical demyelination in early multiple sclerosis</span>. <abbr class="cit-jnl-abbrev">N Engl J Med</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">365</span>:<span class="cit-fpage">2188</span>–<span class="cit-lpage">97</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1056/NEJMoa1100648</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>22150037</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1056/NEJMoa1100648&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=22150037&amp;link_type=MED&amp;atom=%2Fajnr%2F39%2F4%2F642.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a><a href="/lookup/external-ref?access_num=000297731400004&amp;link_type=ISI" class="cit-ref-sprinkles cit-ref-sprinkles-newisilink cit-ref-sprinkles-webofscience"><span>Web of Science</span></a></div></div></li><li><span class="ref-label">6.</span><a class="rev-xref-ref" href="#xref-ref-6-1" title="View reference 6. in text" id="ref-6">↵</a><div class="cit ref-cit ref-journal" id="cit-39.4.642.6" data-doi="10.1093/brain/aws189"><div class="cit-metadata"><ol class="cit-auth-list"><li>
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 39</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 4 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Apr 2018 </div></div>
      
      
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      <div class="highwire-cite-title">Evaluation of Leptomeningeal Contrast Enhancement Using Pre-and Postcontrast Subtraction 3D-FLAIR Imaging in Multiple Sclerosis</div>  
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    	<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">Apr 2018, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">642-647; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A5541 </span></div>
  
  
  
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    	<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">Apr 2018, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">39 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">642-647; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A5541 </span></div>
  
  
  
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