scholarly journals Uterine Artery Pulsatility Index as a Pre-eclampsia Predictor in the 3 Trimesters in Women with Singleton Pregnancies

2021 ◽  
Vol 43 (12) ◽  
pp. 904-910
Author(s):  
Yuly Natalia Guzmán ◽  
Montserrat Uriel ◽  
Alexandra Porras Ramírez ◽  
Ximena Carolina Romero
Keyword(s):  
Pulsatility Index ◽  
Uterine Artery ◽  
Operating Characteristic ◽  
Area Under The Curve ◽  
Roc Curves ◽  
Uterine Arteries ◽  
Kaplan Meier ◽  
High Prevalence ◽  
The Mean ◽  
Singleton Pregnancies

Abstract Objective To evaluate the mean uterine artery pulsatility index (UtAPI) in each trimester of pregnancy as a predictor of early or late pre-eclampsia (PE) in Colombian pregnant women. Methods The UtAPI was measured in singleton pregnancies in each trimester. Uterine artery pulsatility index as predictor of PE was evaluated by odds ratio (OR), receiver operating characteristic (ROC) curves, and Kaplan-Meier diagram. Results Analysis in the 1st and 3rd trimester showed that abnormal UtAPI was associated with early PE (OR: 5.99: 95% confidence interval [CI]: 1.64–21.13; and OR: 10.32; 95%CI: 2.75–42.49, respectively). Sensitivity and specificity were 71.4 and 79.6%, respectively, for developing PE (area under the curve [AUC]: 0.922). The Kaplan-Meier curve showed that a UtAPI of 0.76 (95%CI: 0.58–1.0) in the 1st trimester was associated with early PE, and a UtAPI of 0.73 (95%CI: 0.55–0.97) in the 3rd trimester was associated with late PE. Conclusion Uterine arteries proved to be a useful predictor tool in the 1st and 3rd trimesters for early PE and in the 3rd trimester for late PE in a pregnant population with high prevalence of PE.

scholarly journals Reference Curve for the Mean Uterine Artery Pulsatility Index in Singleton Pregnancies

2017 ◽  
Vol 77 (05) ◽  
pp. 516-523
Author(s):  
Alexander Weichert ◽  
Andreas Hagen ◽  
Michael Tchirikov ◽  
Ilka Fuchs ◽  
Wolfgang Henrich ◽  
...  
Keyword(s):  
Pulsatility Index ◽  
Uterine Artery ◽  
Flow Patterns ◽  
Trophoblast Invasion ◽  
Reference Curve ◽  
Pulsed Doppler ◽  
Increased Risk ◽  
Reference Curves ◽  
The Mean ◽  
Singleton Pregnancies

Abstract Introduction Doppler sonography of the uterine artery (UA) is done to monitor pregnancies, because the detected flow patterns are useful to draw inferences about possible disorders of trophoblast invasion. Increased resistance in the UA is associated with an increased risk of preeclampsia and/or intrauterine growth restriction (IUGR) and perinatal mortality. In the absence of standardized figures, the normal ranges of the various available reference curves sometimes differ quite substantially from one another. The causes for this are differences in the flow patterns of the UA depending on the position of the pulsed Doppler gates as well as branching of the UA. Because of the discrepancies between the different reference curves and the practical problems this poses for guideline recommendations, we thought it would be useful to create our own reference curves for Doppler measurements of the UA obtained from a singleton cohort under standardized conditions. Material and Methods This retrospective cohort study was carried out in the Department of Obstetrics of the Charité – Universitätsmedizin Berlin, the Department for Obstetrics and Prenatal Medicine of the University Hospital Halle (Saale) and the Center for Prenatal Diagnostics and Human Genetics Kurfürstendamm 199. Available datasets from the three study locations were identified and reference curves were generated using the LMS method. Measured values were correlated with age of gestation, and a cubic model and Box-Cox power transformation (L), the median (M) and the coefficient of variation (S) were used to smooth the curves. Results 103 720 Doppler examinations of the UA carried out in singleton pregnancies from the 11th week of gestation (10 + 1 GW) were analyzed. The mean pulsatility index (Mean PI) showed a continuous decline over the course of pregnancy, dropping to a plateau of around 0.84 between the 23rd and 27th GW, after which it decreased again. Conclusion Age of gestation, placental position, position of pulsed Doppler gates and branching of the UA can all change the flow pattern. The mean pulsatility index (Mean PI) showed a continuous decrease over time. There were significant differences between our data and alternative reference curves. A system of classifying Doppler studies and a reference curve adapted to the current technology are urgently required to differentiate better between physiological and pathological findings.

scholarly journals Novel Physique Index for the Screening of Skeletal Dysplasia at Birth

Children ◽  
2021 ◽  
Vol 8 (5) ◽  
pp. 331
Author(s):  
Ryoji Aoki ◽  
Nobuhiko Nagano ◽  
Aya Okahashi ◽  
Shoko Ohashi ◽  
Yoshinori Fujinaka ◽  
...  
Keyword(s):  
Birth Weight ◽  
Skeletal Dysplasia ◽  
Operating Characteristic ◽  
Area Under The Curve ◽  
Roc Curves ◽  
Regression Equations ◽  
Fetal Ultrasound ◽  
The Mean ◽  
Gestational Age At Birth ◽  
Age At Birth

This study aimed to devise a novel physique index and investigate its accuracy in identifying newborns with skeletal dysplasia in comparison with head circumference (HC)/height (HT) ratio. The birth weight (W), HT, and HC at birth of 1500 newborns were retrospectively collected. The linear regression equations and coefficients of determination (R2) were determined. The formulated equation was corrected by the mean weight for gestational age at birth (Wcorr) as a novel physique index for screening skeletal dysplasia. The index accuracy was assessed using receiver operating characteristic (ROC) curves in 11 newborns by fetal ultrasound and compared with that of the HC/HT ratio. The R2 values between W and HT, (HT)2, and (HT) 3 were 0.978, 0.990, and 0.993, respectively. Those between W and HC, (HC)2, and (HC)3 were 0.974, 0.984, and 0.988, respectively. W/Wcorr × (HC/HT)3 was used as a novel physique index. Seven newborns had skeletal dysplasia. Our novel physique index had a higher area under the curve (AUC), sensitivity, and specificity than the HC/HT ratio (AUC: 1.00 vs. 0.86, sensitivity: 1.00 vs. 0.86, and specificity: 1.00 vs. 0.75, respectively). Our novel physique index was more accurate than HC/HT ratio and has the potential to accurately identify newborns with skeletal dysplasia.

scholarly journals Acute or chronic periprosthetic joint infection? Using the ESR ∕ CRP ratio to aid in determining the acuity of periprosthetic joint infections

2021 ◽  
Vol 6 (6) ◽  
pp. 229-234
Author(s):  
Zachary K. Christopher ◽  
Kade S. McQuivey ◽  
David G. Deckey ◽  
Jack Haglin ◽  
Mark J. Spangehl ◽  
...  
Keyword(s):  
Periprosthetic Joint Infection ◽  
Operating Characteristic ◽  
Joint Infection ◽  
Area Under The Curve ◽  
Roc Curves ◽  
Chronic Patients ◽  
Joint Infections ◽  
The Mean ◽  
Acute Patients ◽  
The Ideal

Abstract. Introduction: The gold standard for determining the duration of periprosthetic joint infection (PJI) is a thorough history. Currently, there are no well-defined objective criteria to determine the duration of PJI, and little evidence exists regarding the ratio between ESR (mm/h) and CRP (mg/L) in joint arthroplasty. This study suggests the ESR / CRP ratio will help differentiate acute from chronic PJI. Methods: Retrospective review of patients with PJI was performed. Inclusion criteria: patients >18 years old who underwent surgical revision for PJI and had documented ESR and CRP values. Subjects were divided into two groups: PJI for greater (chronic) or less than (acute) 4 weeks and the ESR / CRP ratio was compared between them. Receiver-operating characteristic (ROC) curves were evaluated to determine the utility of the ESR / CRP ratio in characterizing the duration of PJI. Results: 147 patients were included in the study (81 acute and 66 chronic). The mean ESR / CRP ratio in acute patients was 0.48 compared to 2.87 in chronic patients (p<0.001). The ESR / CRP ROC curve demonstrated an excellent area under the curve (AUC) of 0.899. The ideal cutoff value was 0.96 for ESR / CRP to predict a chronic (>0.96) vs. acute (<0.96) PJI. The sensitivity at this value was 0.74 (95 % CI 0.62–0.83) and the specificity was 0.90 (95 % CI 0.81–0.94). Conclusions: The ESR / CRP ratio may help determine the duration of PJI in uncertain cases. This metric may give arthroplasty surgeons more confidence in defining the duration of the PJI and therefore aid in treatment selection.

scholarly journals Maternal Serum Concentrations of Corin, Endoglin, PP13, and sFlt-1 and their Changes with Advancement of Pregnancy and Correlation with Doppler of Uterine Arteries

Folia Medica ◽  
2018 ◽  
Vol 60 (4) ◽  
pp. 558-564
Author(s):  
Krasimira I. Chalova ◽  
Blagovest K. Pehlivanov ◽  
Iliya G. Amaliev ◽  
Georgi I. Amaliev ◽  
Ralitsa D. Raycheva ◽  
...  
Keyword(s):  
Pulsatility Index ◽  
Uterine Artery ◽  
Maternal Serum ◽  
Serum Concentrations ◽  
Uterine Arteries ◽  
Prediction And Prevention ◽  
Significant Difference ◽  
Gestational Week ◽  
The Mean ◽  
Experimental Group

Abstract Background: Pre-eclampsia (PE) affects 2% to 5% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality worldwide. Since PE has complex pathogenesis and treatment is still not found, effective methods for prediction and prevention of PE are still actively searched. Aim: The aim of this study was to find the mean maternal serum concentration of four proteins in Bulgarian pregnant women and to investigate the correlation with uterine artery pulsatility index in the first and second trimester of pregnancy. Materials and methods: In this prospective case-control study, maternal serum concentrations of corin, sEndoglin, PP13, and sFlt-1 were measured, pulsatility index of uterine artery (PI-UA) was assessed in 40 women with Doppler, twice during pregnancy – at the 11th – 13th weeks of gestation and the 20th gestational week. They were randomized in two groups: an experimental group: with increased PIUA at gestational week 13 and a control group: with normal PI-UA. All pregnancies were followed up until the day of delivery and outcomes were recorded. Results: There was no significant difference in the APGAR score and birth weight of the newborns between groups. We found no significant difference in the mean concentration of sEnd, sFlt-1 and PP13 between 11-13 weeks of gestation and 20 week of gestation in the control and experimental groups. Statistically significant difference was found only in the mean concentrations of corin between weeks 11-13 and week 20 in both control (t=3.27; p=0.004) and experimental group (t=3.22; p=0.005). Corin levels and the mean PI of uterine arteries tended to decrease with progression of pregnancy in both groups. Conclusions: Further prospective studies of larger populations are required to develop a panel of multiple predictors for PE.

ESR and CRP Diagnostic Thresholds for Prosthetic Joint Infection in Hip Hemiarthroplasty

2020 ◽  
Vol 4 (04) ◽  
pp. 187-192
Author(s):  
Jared A. Warren ◽  
Oliver Scotting ◽  
Hiba K. Anis ◽  
James Bircher ◽  
Alison K. Klika ◽  
...  
Keyword(s):  
Prosthetic Joint Infection ◽  
Joint Infection ◽  
Area Under The Curve ◽  
Roc Curves ◽  
Musculoskeletal Infection ◽  
Hip Hemiarthroplasty ◽  
Diagnostic Thresholds ◽  
Diagnostic Threshold ◽  
Prosthetic Joint ◽  
The Mean

AbstractDiagnostic thresholds used to standardize the definition for prosthetic joint infection (PJI) have largely focused on total joint arthroplasty (TJA). Established PJI thresholds exist for serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in TJA; however, they do not exist for revision hip hemiarthroplasty (rHHA). The purpose of this study was to establish thresholds for (1) ESR and (2) CRP to diagnose PJI in rHHA. Data were collected on a prospective cohort of 69 rHHA patients undergoing orthopaedic surgery between 1/2017 and 2/2019 in a single health care system. Procedures were categorized as septic or aseptic revisions using Musculoskeletal Infection Society (MSIS) criteria (2013). There were 44 ESRs (n = 28 aseptic, n = 16 septic) and 46 CRPs (n = 29 aseptic, n = 17 septic) available for analysis. Two tailed t-tests were performed to compare the mean ESR and CRP in aseptic and septic cases. Receiver operator characteristic (ROC) curves were generated to obtain diagnostic cutoff thresholds using the Youden's Index (J) for ESR and CRP. The mean ESR was 50.3 ± 30.6 mm/h versus 15.4 ± 17.7 mm/h (p < 0.001), while the mean CRP was 29.9 ± 24.8 mg/L versus 4.1 ± 8.2 mg/L (p < 0.001) for septic and aseptic revisions, respectively. The diagnostic threshold for PJI determined by the ROC curve was 44 mm/h for ESR (sensitivity = 56.3%; specificity = 100.0%; J = 0.563; area under the curve (AUC) = 0.845), while it was 12.5 mg/L for CRP (sensitivity = 70.6%; specificity = 96.6%; J = 0.672; AUC = 0.896). For patients with HHA, an ESR of 44 mm/h was and a CRP of 12.5 mg/L was highly specific for PJI. The thresholds are similar to the MSIS thresholds currently published. Larger prospective trials are needed to establish more robust and conclusive diagnostic criteria for PJI in HHA, including investigations not only of ESR and CRP but synovial white blood cell count and synovial polymorphonuclear leukocytes % as well.

scholarly journals Soluble SIGLEC5: A New Prognosis Marker in Colorectal Cancer Patients

Cancers ◽  
2021 ◽  
Vol 13 (15) ◽  
pp. 3896
Author(s):  
Karla Montalbán-Hernández ◽  
Ramón Cantero-Cid ◽  
Roberto Lozano-Rodríguez ◽  
Alejandro Pascual-Iglesias ◽  
José Avendaño-Ortiz ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Operating Characteristic ◽  
Prognostic Markers ◽  
Characteristic Curve ◽  
Area Under The Curve ◽  
Significant Heterogeneity ◽  
Kaplan Meier ◽  
Prognosis Marker ◽  
Colorectal Cancer Patients ◽  
Healthy Participants

Colorectal cancer (CRC) is the second most deadly and third most commonly diagnosed cancer worldwide. There is significant heterogeneity among patients with CRC, which hinders the search for a standard approach for the detection of this disease. Therefore, the identification of robust prognostic markers for patients with CRC represents an urgent clinical need. In search of such biomarkers, a total of 114 patients with colorectal cancer and 67 healthy participants were studied. Soluble SIGLEC5 (sSIGLEC5) levels were higher in plasma from patients with CRC compared with healthy volunteers. Additionally, sSIGLEC5 levels were higher in exitus than in survivors, and the receiver operating characteristic curve analysis revealed sSIGLEC5 to be an exitus predictor (area under the curve 0.853; cut-off > 412.6 ng/mL) in these patients. A Kaplan–Meier analysis showed that patients with high levels of sSIGLEC5 had significantly shorter overall survival (hazard ratio 15.68; 95% CI 4.571–53.81; p ≤ 0.0001) than those with lower sSIGLEC5 levels. Our study suggests that sSIGLEC5 is a soluble prognosis marker and exitus predictor in CRC.

scholarly journals The Use of Biochemical and Biophysical Markers in Early Screening for Preeclampsia in Mongolia

2018 ◽  
Vol 6 (3) ◽  
pp. 57
Author(s):  
Urjindelger Tserensambuu ◽  
Ariunbold Chuluun-Erdene ◽  
Munkhtsetseg Janlav ◽  
Erkhembaatar Tudevdorj
Keyword(s):  
Mean Arterial Pressure ◽  
Arterial Pressure ◽  
Pulsatility Index ◽  
Uterine Artery ◽  
Maternal Serum ◽  
Operating Characteristics ◽  
Early Screening ◽  
Roc Curve Analysis ◽  
Detection Rates ◽  
The Mean

Preeclampsia (PE) is a major cause of maternal and perinatal morbidity and mortality, particularly in developing countries. In Mongolia, preeclampsia and eclampsia have occurred among pregnancy complications at a rate of 25% in recent years. Recent studies in the literature have screened for preeclampsia by combining maternal factors with biomarkers. This study was conducted using prospective cohort research including 393 singleton pregnancies at 11–13+6 weeks. Maternal plasmas pregnancy-associated plasma protein-A (PAPP-A) and maternal serum placental growth factor (PlGF) were measured using Perkin Elmer time-resolved fluoroimmunoassay (DELFIA) kits, and the measurement of mean arterial pressure (MAP) was performed by automated devices and the uterine artery pulsatility index was measured by Doppler ultrasound. In the study population, there were 16.7% showing complicated preeclampsia. The receiver-operating characteristics (ROC) curve analysis showed a sensitivity of 71.21%, and a specificity of 75.54% when the mean arterial pressure cut-off was 89.5 mm; while a sensitivity of 33.36% and specificity of 77.68% were observed when the uterine artery mean pulsatility index (mPI) cut-off was 2.34; a sensitivity of 79.66% and specificity of 44.04% were observed when the PAPP-A cut-off was 529.1 mU/L; and a sensitivity of 74.58% and specificity of 46.6% were observed when the PlGF cut-off was 39.87 pg/mL. The detection rates following the combination of markers with the maternal history were as follows: 62.7% with mean arterial pressure, 69.5–82.9% with two markers 86.5% with three markers and 91.4% with four markers. In conclusion, the mean arterial pressure was highly sensitive and demonstrated its easy usage and cost-effectiveness as a predictive marker for the early screening of preeclampsia from other biomarkers.

Ultrasound grayscale ratio: a reliable parameter for differentiating papillary thyroid microcarcinoma from micronodular goiter

2020 ◽  
Author(s):  
Chenke Xu ◽  
Lifang Yu ◽  
Jianhua Fang ◽  
Zhijiang Han ◽  
Dingcun Luo ◽  
...  
Keyword(s):  
Operating Characteristic ◽  
Roc Curves ◽  
Mean Value ◽  
Papillary Thyroid ◽  
Diagnostic Efficacy ◽  
Receiver Operating Characteristic Curves ◽  
Thyroid Microcarcinoma ◽  
Reliable Parameter ◽  
The Mean ◽  
Reading System

Abstract Background: To evaluate the reliability and diagnostic efficacy of the ultrasound grayscale ratio (UGSR) for differentiating papillary thyroid microcarcinomas (PTMC) from micronodular goiters (diameter ≤ 1.0cm).Methods: The ultrasound data of 241 pathologically-confirmed cases of patients with 265 PTMC and 141 patients with 168 micronodular goiters were retrospectively reviewed. All patients underwent outpatient ultrasonic examination and preoperative ultrasonic positioning. The RADinfo radiograph reading system (Zhejiang RAD Information Technology Co., Ltd., China) was used to measure and calculated the UGSR of PTMC, micronodular goiters. Patients were divided into the outpatient examination, preoperative positioning, and mean value groups, and the receiver operating characteristic curves (ROC) were calculated to obtain the optimal UGSR threshold for distinguishing PTMC from micronodular goiters.Results: The UGSR values of the PTMC and micronodular goiters were 0.56±0.14 and 0.80±0.19 (t=5.84, P<0.01) in the outpatient examination group, 0.55±0.14 and 0.80±0.19 (t=18.74, P<0.01) in the preoperative positioning group, and 0.56±0.12 and 0.80±0.18 (t=16.49, P<0.01) in the mean value group. The areas under the ROC curves in the outpatient examination, preoperative positioning, and mean value groups were 0.860, 0.856, and 0.875, respectively. When the cut-off UGSR values for the outpatient examination, preoperative positioning, and mean value groups were 0.649, 0.646, and 0.657, the sensitivity and specificity for predicting PTMC were 78.9% and 86.9%, 79.2% and 83.9%, 82.6%, and 85.7%, respectively. A reliable UGSR value was obtained between the outpatient examination and preoperative positioning groups (ICC=0.79, P=0.68).Conclusion: The UGSR is an accurate and feasible tool for differentiating PTMC from micronodular goiters with better diagnostic efficacy.

scholarly journals Relation of serum visfatin level and uterine artery Doppler to preeclampsia

2017 ◽  
Vol 7 (1) ◽  
pp. 48 ◽  
Author(s):  
Mohamed Abd El-Moety El-Samra ◽  
Sherif Mansour Aggag
Keyword(s):  
Doppler Ultrasound ◽  
Pulsatility Index ◽  
Uterine Artery ◽  
Pulsed Doppler ◽  
Maternal Circulation ◽  
Cross Sectional ◽  
Uterine Arteries ◽  
Pregnant Females ◽  
Mild Preeclampsia ◽  
Visfatin Level

Background: Preeclampsia (PE) is a significant cause of remarkable fetomaternal morbidity and mortality worldwide. Visfatin is 52 KDa novel adipokine, pre B cell colony enhancing factor (PBEF) which could be used as a biochemical marker predictor or a diagnostic tool for preeclampsia. Trans abdominal pulsed Doppler ultrasound (US) monitor the impedance to blood flow in the uterine arteries in pregnant females and those with preeclampsia. Visfatin has been implicated in the pathogenesis of preeclampsia with a limited contradictory. The aim of our study is to monitor the risky pregnant females through Visfatin level and transabdominal pulsed Doppler of the uterine artery.Methods: Assessment of the serum Visfatin levels in the maternal circulation of preeclamptic pregnant females wether mild or severe, and compared to those in the normal pregnant subjects as control through recruitment of cases of mild PE (n=40), severe PE (n=40), normal pregnant subjects (n=60) in a cross sectional study where the cases were of the patients hospitalized at El Shatby Hospital of Obstetrics and Gynecology, and the control subjects were of referrals to the outpatient departments. Fasting blood samples were drawn, kept at -20 degree centigrades , enzyme linked immune sorbant assay (ELISA) Test was performed on them to determine the Visfatin level and recorded the uterine arteries pulsatility index through transabdominal doppler ultrasound. Lastly, the data were analysed using (F test) ANOVA statistical method.Results: Amongst the groups, Serum visfatin level was significantly higher in the severe preeclamptic group rather than the normal pregnant group and those with mild preeclampsia (p<0.001). Uterine artery pulsatility index was significantly higher in the severe preeclamptic group rather than the normal pregnant group and those with mild preeclampsia (p<0.001).Conclusions: Severe preeclamptic pregnant females were shown to represent higher circulating visfatin levels as one of the most recent biochemical markers of preeclampsia, higher uterine artery pulsatility index compared to normal pregnant and those with mild preeclamptic groups of women.

scholarly journals Doppler ultrasound for diagnosis of soft tissue sarcoma: efficacy of ultrasound-based screening score

2015 ◽  
Vol 49 (2) ◽  
pp. 135-140 ◽  
Author(s):  
Satoshi Nagano ◽  
Yuhei Yahiro ◽  
Masahiro Yokouchi ◽  
Takao Setoguchi ◽  
Yasuhiro Ishidou ◽  
...  
Keyword(s):  
Doppler Ultrasound ◽  
Ultrasound Imaging ◽  
Operating Characteristic ◽  
Soft Part ◽  
Imaging Modality ◽  
Screening Method ◽  
Area Under The Curve ◽  
Roc Curve Analysis ◽  
Diagnostic Efficacy ◽  
The Mean

Abstract Background. The utility of ultrasound imaging in the screening of soft-part tumours (SPTs) has been reported. We classified SPTs according to their blood flow pattern on Doppler ultrasound and re-evaluated the efficacy of this imaging modality as a screening method. Additionally, we combined Doppler ultrasound with several values to improve the diagnostic efficacy and to establish a new diagnostic tool. Patients and methods. This study included 189 cases of pathologically confirmed SPTs (122 cases of benign disease including SPTs and tumour-like lesions and 67 cases of malignant SPTs). Ultrasound imaging included evaluation of vascularity by colour Doppler. We established a scoring system to more effectively differentiate malignant from benign SPTs (ultrasound-based sarcoma screening [USS] score). Results. The mean scores in the benign and malignant groups were 1.47 ± 0.93 and 3.42 ± 1.30, respectively. Patients with malignant masses showed significantly higher USS scores than did those with benign masses (p < 1 × 10-10). The area under the curve was 0.88 by receiver operating characteristic (ROC) analysis. Based on the cut-off value (3 points) calculated by ROC curve analysis, the sensitivity and specificity for a diagnosis of malignant SPT was 85.1% and 86.9%, respectively. Conclusions. Assessment of vascularity by Doppler ultrasound alone is insufficient for differentiation between benign and malignant SPTs. Preoperative diagnosis of most SPTs is possible by combining our USS score with characteristic clinical and magnetic resonance imaging findings.

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