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ABSTRACT |
Thursday, May 10, 10:00 AM–12:00 PM
Abstracts 239-249
Moderator(s): Laurie Loevner and Michelle Johnson
10:00 AM
Keynote Address: Vascular Lesions of the Head and Neck
Michelle Johnson, Yale University, New Haven, CT
10:10 AM
239. Role of Diffusion-weighted MR Imaging and Dynamic Contrast Enhanced Echoplanar MR in Differentiation of Recurrent Head and Neck Tumors from Post Radiation Changes
Abdel Razek A.*; Kandeel A. Mansoura Faculty of Medicine, Mansoura, Egypt
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To assess the clinical usefulness of apparent diffusion coefficient map and dynamic contrast enhanced echo planar MR imaging for differentiation recurrent head and neck tumors from post radiation changes.
Materials and Methods: Prospective study was conducted on 33 consecutive patients (21M, 12F aged 39-73 years: mean 51years) with head and neck cancer after complete course of radiotherapy. Diffusion MR images were acquired with a b-factor of 0,500 and 1000 sec/mm2 using a single shot echo planar imaging. Multislice dynamic contrast enhanced single shot echoplanar T2*-weighted MR imaging was done after bolus infusion of Gadolinium-DTPA at a dose of 0.2 ml mol/kg BW every 2 seconds for 2minutes. The mean apparent diffusion coefficient (ADC) value and percentage of maximum signal intensity loss of the lesion was calculated and correlated with pathological finding
Results: The mean ADC value of recurrent head and neck tumor (1.21 ± 0.13 x 10-3 mm2/sec) was significantly lower than those of post radiation changes (1.63 ± 0.09 x 10-3 mm2/sec). The mean percentage of maximum signal intensity loss of recurrent tumor was 33.6% and of post radiation changes was 14.55%. There was statistically difference in ADC (p < 0.004) and in maximum percentage of signal intensity loss (p < 0.03) between recurrent tumor and post radiation changes. Selection of ADC value of 1.23 x 10-3 mm2/sec and maximum signal intensity loss of 22.6% as the thresholds to predict recurrence has sensitivity of 91% and 89% and specificity of 93% and 91% and accuracy of 94% and 92%, respectively.
Conclusion: We concluded that apparent diffusion coefficient map and dynamic contrast-enhanced echoplanar MR imaging increased diagnostic performance of MR imaging in differentiation recurrent tumor from post radiation changes in patients with head and neck cancer.
240. Assessment of Cervical Lymphadenopathy with Diffusion-weighted MR and Dynamic Contrast Enhanced T2*-Weighted First Pass Perfusion MR Imaging
Abdel Razek A.*; Nada N.; Tawfik A. Mansoura Faculty of Medicine, Mansoura, Egypt
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To assess the clinical usefulness of diffusion weighted MR imaging and dynamic contrast enhanced T2*-weighted first pass perfusion MR imaging for characterization of cervical lymph nodes.
Materials and Methods: This study included 42 consecutive patients (27M, 15F aged 13-72 years: mean 45 years) with cervical lymph nodes. Diffusion MR-weighted imaging was done using echo planar imaging with calculation of apparent diffusion coefficient (ADC) value. Multislice single shot echoplanar T2*-weighted first pass perfusion MR imaging was done after bolus infusion of gadolinium-DTPA at a dose of 0.2 ml mol/kg BW every 2 seconds for 2 minutes. Only lymph nodes larger than 5 mm were evaluated. Histopathological examination revealed malignant (49 metastasis, 21 lymphoma) and benign (11 reactive and 4 granulomatous) nodes. Statistical analysis was done in form of sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV).
Results: The mean ADC value of malignant lymph nodes (1.09 ± 0.13 x 10-3 mm2/sec) was significantly lower than those of benign lymph nodes (1.57 ± 0.11 x 10-3 mm2/sec).The mean percentage of maximum signal intensity loss of malignant nodes was 47.3 ± 8.2% and of benign nodes was 18.7 ± 3.9%. There was statistically difference for ADC value (p < 0.02) and for maximum percentage of signal intensity loss (p < 0.004) between benign and malignant nodes. The threshold value of ADC value was 1.31 x 10-3 mm2/sec to differentiate malignant from benign nodes provided accuracy of 95%, sensitivity 92%, specificity 100%, PPV 98% and NPV 90%. Selection of 29.5% as a threshold parameter for maximum signal intensity loss has 98% accuracy, 94% sensitivity, 100% specificity, 99% PPV and 98% NPV.
Conclusion: We concluded that diffusion-weighted MR imaging and dynamic contrast enhanced T2*-weighted first pass perfusion MR imaging are new noninvasive promising methods that used for characterization of cervical lymph nodes.
241. Predication of Malignancy in Head and Neck Tumors Using T2*-weighted Echoplanar First Pass Perfusion Weighted MR Imaging
Abdel Razek A.*; Elserougy L.; Nada N.; Soliman N. Mansoura Faculty of Medicine, Mansoura, Egypt
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To determine the role of T2*-weighted echoplanar first pass perfusion weighted MR imaging in prediction of malignancy in head and neck tumors.
Materials and Methods: Prospective study was conducted on 51 consecutive patients (37M, 14F aged 15–63 years: mean 49 years) with head and neck tumors. They underwent multislice single shot echoplanar T2*-weighted first pass perfusion MR imaging using 1.5 T unit. Bolus infusion of gadolinium-DTPA was administered in a dose of 0.2 ml mol/kg BW after 8 seconds. Image acquisition was repeated every 2 seconds for 120 seconds. Imaging parameters were: TR = 120 ms, TE = 47 ms, slice thickness = 5 mm, gap = 2 mm, NEX = 1. The images were processed and lesion signal intensity versus time curve was created. The parameters investigated were: maximum signal intensity (SI) loss, time to reach maximum SI loss and SI recovery time. These parameters were compared with histopathological findings. Receiver operating curve (ROC) was done with calculation of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).
Results: There was statistically difference for maximum SI loss (p < 0.001) and time for SI recovery (p < 0.03) and insignificant difference for time for maximum SI loss (p = 0.1) between benign and malignant head and neck tumors. Selection of 29% for percentage of maximum signal intensity loss and 4.6 for time for signal intensity loss as a threshold to predict malignancy provided accuracy of 91% and 86%, sensitivity of 90% and 83%, specificity of 92% and 91%, PPV of 92% and 93% and NPV of 90% and 78%, respectively.
Conclusion: T2*-weighted echoplanar first pass perfusion weighted MR imaging play a complementary role in prediction of malignancy in head and neck tumors.
242. Characterization of Nasal Masses with Diffusion-weighted Echoplanar MR Imaging
Abdel Razek A.1*; Emam H.1, Gibson D.2; 1. Mansoura Faculty of Medicine, Mansoura, Egypt; 2. William Beaumont Hospital, Royal Oak, MI
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To evaluate the role of diffusion-weighted echoplanar MR imaging in patients with nasal mass.
Materials and Methods: Prospective study was conducted on 55 consecutive patients (34M, 21F aged 9–64 years: mean 51 years) with nasal mass. They underwent diffusion-weighted MR imaging using a single shot echo planar imaging with a b-factor of 0,500 and 1000 sec mm2. The scanning parameters were: TR = 10000 ms, TE = 108 ms, NEX = 2, bandwidth = 125 kHz, slice thickness = 3 mm. Apparent diffusion coefficient (ADC) map was reconstructed. The ADC value of the nasal mass was calculated and correlated with surgical findings or biopsy.
Results: Adequate ADC maps were obtained in 51 patients. There was statistically difference in mean ADC values between malignant nasal tumors and benign lesions (p < 0.021) and within the malignant tumor (p < 0.04). When apparent diffusion coefficient value of 1.27 x 10-3 mm2/sec was used as a threshold value for differentiating of malignant tumors from benign lesions, the best result was obtained with an accuracy of 95%, sensitivity 92%, specificity 96%, positive predictive value 92% and negative predictive value of 96%.
Conclusion: Apparent diffusion coefficient value is a new noninvasive imaging parameter that can be used for characterization of nasal masses as it helps in differentiation benign nasal mass from malignant tumor and offer useful information for the assessment of the histologic type of nasal malignancy.
243. Sonographic Appearance of Thyroid Tumors with Different Aggressiveness and Metastatic Potential
Lyshchik A.1,3; Moses R.3; Barnes S. L.2; Higashi T.1; Miga M. I.3; Fleischer A. C.*3 1. Kyoto University Graduate School of Medicine, Kyoto, Japan; 2. Vanderbilt University, Department of Biomedical Engineering, Nashville, TN; 3. Vanderbilt University Medical Center, Department of Radiology and Radiological Sciences, Nashville, TN
Address correspondence to A. Lyshchik (andrej.lyshchik{at}vanderbilt.edu)
Objective: The purpose of our study was to analyze the sonographic appearance of papillary thyroid carcinomas (PTC) with different aggressiveness and metastatic potential, assessed based on a combined histological examination of nuclear atypia, tumor necrosis, vascular invasions, and extrathyroid spread.
Materials and Methods: Fifty-six thyroid cancer lesions in 43 consecutive patients (mean age 53.5 ± 12.2 years [range 25-74 years], 13 men and 30 women) were included in our study. All patients were examined with B-mode and power Doppler sonography and underwent surgery. The final diagnosis was based on histopathological examination of the resected thyroid specimens. The following ultrasound characteristics were evaluated: echogenicity, internal structure, outline, presence of "Halo," microcalcifications and increased intranodular vascularization. Accuracy of sonographic criteria for thyroid cancer with different aggressiveness and metastatic potential was evaluated with univariate analysis.
Results: Both aggressive and non-aggressive PCT types had a compatible size, internal structure, regularity of the boarder outline, presence of microcalcifications and increased intranodular vascularization. On the other hand, aggressive PTCs examined in our study were significantly more hypoechoic that non-aggressive ones (mean pixel intensity ratio 1.99 ± 0.55 vs. 1.28 ± 0.31, p < 0.001, respectively). Mean pixel intensity ratio >1.6 could provide a valuable criteria for aggressive PTC diagnosis with 86.7% sensitivity and 87.0% specificity.
Conclusion: Our study indicates that ultrasound examination can be successfully used to select PTC lesions with more aggressive behavior and high metastatic potential, by detection mean pixel intensity ratio >1.6.
244. Importance of Vascular Patterns of Thyroid Nodules on Color Doppler Ultrasound in Distinguishing Malignant from Benign Lesions
Yeh D.*; Lee S. Pusan National University Hospital, Pusan, South Korea
Address correspondence to D. Yeh (phinehas{at}paran.com)
Objective: To establish the accuracy of the vascular patterns of thyroid nodules on color Doppler sonography in differentiating malignant from benign lesions.
Materials and Methods: Sonographic features of 12 malignant and 35 benign thyroid nodules were retrospectively analyzed with a main respect to vascular patterns, as well as size, echogenicity, echo structure, shape, margin, and calcification. We divided the color Doppler vascular patterns of thyroid nodules into three categories: I, absence of signal of blood flow; II, basket or covering pattern; III, penetrating pattern. These flow patterns on color Doppler ultrasound were analyzed for their sensitivity, specificity, and accuracy in differentiating malignant from benign lesions.
Results: Of 35 benign nodules, 30 (85.7%) had the basket pattern, five (14.3%) had the absence of signal of blood flow. Penetrating flow pattern was not observed in the benign nodules. Twelve malignant nodules had the penetrating pattern in ten (83.3%), basket pattern in one (8.3%) and absence of signal of blood flow in one (8.3%). Diagnostic characteristics of penetrating flow pattern on color Doppler sonography for differentiating malignant from benign lesion were sensitivity 83.3%, specificity 100%, accuracy 95.7%.
Conclusion: The vascular patterns of thyroid nodule on color Doppler sonography may be one of the most reliable signs of thyroid malignancy.
245. Radiologic and Pathologic Findings of Minimal Thyroid and Ordinary Thyroid Cancers Incidentally Detected in Health Screening Center: Evaluation of the Value of Size Criteria 1 cm in Recommending FNA
Kim J.*; Kim S.; Cho K. Seoul National University Hospital Healthcare System Gangnam Center, Seoul, South Korea
Address correspondence to J. Kim (Myniceboys{at}naver.com)
Objective: To analyze radiologic and pathologic findings of minimal thyroid and ordinary thyroid cancers detected on screening thyroid US and evaluation of the value of size criteria 1 cm in recommending FNA.
Materials and Methods: Of 149 thyroid nodules undergone fine-needle aspiration (FNA) and reported as suspicious malignancy from April 2004 to June 2006, 62 nodules in 59 patients were confirmed as malignancy after thyroidectomy. Forty were minimal thyroid cancers (equal or less than 1 cm) and 22 ordinary thyroid cancers (larger than 1 cm). Two radiologists analyzed US features of nodules for size, echogenicity, shape, margin, calcification, and degree of cystic change. Combined numbers of high-risk US findings for echogenicity, shape, margin and calcification of each nodule were calculated. Pathologic findings for extracapsular invasion, LN metastasis, bilaterality and multicentricity were compared. The differences were identified using Chi-square or Fisher's exact test.
Results: All 62 cancers were papillary type. Mean largest diameter was 9.5 mm (7.4 ± 2.3 mm and 13.0 ± 5.5 mm respectively, range 3.8-25.2 mm). Marked hypoechogenicity (53.2%), ovoid or round shape (46.8%), well-defined spiculated margin (51.6%), microcalcifications (35.5%), and entirely solid nature (93.5%) were commonly observed US characteristics. No significant differences have been found in US findings between two groups. The mean of combined numbers of high-risk US characteristics per each nodule were 2.4 ± 1.0 mm in minimal cancer and 2.7 ± 1.0 mm in ordinary cancer without statistical difference. Only three (7.5%) in minimal cancer and one (4.5%) in ordinary cancer showed none of high-risk US finding. Extracapsular invasion (p = 0.02) and LN metastasis (p = 0.01) were significantly more frequent in ordinary cancer (68.2%, 40.9%, respectively) than minimal cancer (37.5%, 12.5%, respectively). For multicentricity and bilaterality, no statistical differences has been found.
Conclusion: As for incidentally detected thyroid nodules, the size criteria of 1 cm has little value in deciding on which nodule to perform FNA.
246. Imaging of Major Brain Arteries in Children with Sickle Cell Disease: Transcranial Color-coded Duplex Sonography Versus Conventional Transcranial Doppler Sonography
Krejza J.2*; Rudzinski W.2; Pawlak M. A.2; Tomaszewski M.2; Kwiatkowski J.1; Melhem E.2 1. Children Hospital of Philadelphia, Philadelphia, PA; 2. University of Pennsylvania, Philadelphia, PA
Address correspondence to J. Krejza (jaroslaw.krejza{at}uphs.upenn.edu)
Objective: To compare transcranial color-coded duplex sonography (TCCS) with non-imaging transcranial Doppler sonography (TCD) in children with sickle cell disease (SCD).
Materials and Methods: 37 children (mean age 7.8 ± 3.0 years) without intracranial arterial narrowing, determined with magnetic resonance angiography, were studied using TCD and TCCS at the same session. TCCS mean blood flow velocity with and without correction for the angle of insonation in the terminal internal carotid artery (ICA), middle (MCA), anterior (ACA), and posterior (PCA) cerebral arteries was compared to TCD velocity. Depth of insonation in both methods was also compared.
Results: Using TCCS two arteries were not found compared to 15 not found with TCD. Average angle of insonation in the MCA, ACA, ICA and PCA was 31°, 44°, 25° and 29°, respectively. Insonation depth for all arteries was similar for both methods; however, differences in individual arteries varied substantially. The uncorrected TCCS velocities were on average 20% lower than corresponding TCD velocities; respectively for the right and left sides mean and standard deviation: MCA 106 ± 22 cm/s, 111 ± 33 cm/s versus 130 ± 19 cm/s, 134 ± 26 cm/s; ICA 90 ± 14 cm/s, 98 ± 27 cm/s versus 117 ± 18 cm/s; 119 ± 23 cm/s; ACA 74 ± 24 cm/s, 88 ± 25 cm/s versus 105 ± 23 cm/s, 105 ± 31 cm/s; PCA 84 ± 27 cm/s, left 82 ± 21 cm/s versus 95 ± 23 cm/s, 94 ± 20 cm/s. The angle-corrected velocities were similar to TCD velocities except for higher TCCS values in the left ACA and right PCA.
Conclusion: TCCS is more successful in vessels identification than TCD. Angle-corrected TCCS velocities are similar to TCD velocities whereas uncorrected ones are substantially lower. Usefulness of TCCS in stroke risk estimation in SCD children warrants further studies.
247. Sickle Cell Disease: Ratios of Blood Flow Velocities of Intracranial to Extracranial Cerebral Arteries in Children with No Arterial Narrowing
Krejza J.2*; Rudzinski W.2; Pawlak M. A.2; Tomaszewski M.2; Kwiatkowski J.1; Melhem E.2 1. Children Hospital of Philadelphia, Philadelphia, PA; 2. University of Pennsylvania, Philadelphia, PA
Address correspondence to J. Krejza (jaroslaw.krejza{at}uphs.upenn.edu)
Objective: Accuracy of TCD velocity in prediction of stroke in children with sickle cell disease (SCD) is affected by inability to differentiate flow velocity increase due to arterial narrowing from hyperemia. Velocity ratios can be more accurate; yet reference values are not established. We provide reference values for VMCA/VICA and VtICA/VICA ratios in SCD children without neurological deficits and intracranial artery narrowing in MR angiography.
Materials and Methods: Angle-corrected velocities in middle cerebral arteries (MCA), terminal, and proximal internal carotid arteries (ICA) were obtained with transcranial color-coded and carotid duplex sonography (2-MHz and 9-MHz probes, HDI 5000) from 38 children (3-13 years old, 7.9 ± 3.0; 20 M, 18 F). The ratios were calculated by referencing intracranial velocities to respective extracranial ICA velocities.
Results: Ratios were not dependent on age, gender, hematocrit, and hemoglobin levels. Mean and reference ranges of VMCA/VICA for the peak-systolic, mean and end-diastolic velocities are 1.6 (0.8-2.4), 1.9 (0.7-3.1), 1.9 (0.7-3.1). Respective values for VtICA/VICA are 1.4 (0.6-2.2), 1.7 (0.7-2.7), 1.5 (0.5-2.5).
Conclusion: The reference ranges of velocity ratios can help discriminate intracranial artery narrowing from hyperemia in children with SCD.
248. Analysis of Signal Intensity Changes Representing Brain Maturation During the First Postnatal Year
Provenzale J. M.3*; Liang L. L.1; York G. E.2; DeLong D. M.3; White L. E.3 1. Beaconbioscience, Doylestown, PA; 2. Brooke Army Medical Center, San Antonio, TX; 3. Duke University Medical Center, Durham, NC
Address correspondence to J. Provenzale (prove001{at}mc.duke.edu)
Objective: To provide normative data for MR signal intensity (SI) changes reflecting myelination in infants.
Materials and Methods: The study population consisted of 54 infants relatively equally distributed through first 12 months of life who underwent clinical axial T1WI and T2WI imaging (1.5-T scanner). All had normal scans and no neurological abnormality at 5-year clinical follow-up. Two blinded radiologists scored SI of 9 regions: frontal white matter (FWM), occipital WM (OWM), genu (GENU) and splenium (SPLEN) of corpus callosum, posterior limb (PLIC) anterior limb (ALIC) of internal capsule, coronal radiata (CR), cerebral peduncle (CP), and middle cerebellar peduncle (MCP). Scoring criteria for T1WI: -1 (mildly hypointense to cortex), 0 (isointense), 1 (mildly hyperintense), 2 (moderately hyperintense), 3 (markedly hyperintense); for T2WI: -1 (mildly hyperintense to cortex), 0 (isointense), 1 (mildly hypointense), 2 (moderately hypointense), 3 (markedly hypointense). We used ordinal logistic regression models to estimate ages at which probability of attaining Sl scores was 90% (90prob) with 95% confidence intervals [CI] (occasionally not determinable [nd]).
Results: At birth, on T1WI, PLIC, MCP and CR in all infants had a score of +1. By 6 months, SPLEN (4.9 [4.0-6.3]), ALIC (5.8 [4.5-8.3] and OWM (5.9 [5.1-7.7]) had a 90prob of +1 score. At 9 months, GENU (6.4 [5.6-7.7]), CP (7.2 [4.9-12.9]) and FWM (9.1 [8.0-11.3]) had a 90prob of +1 score. Ages of 90prob of score of +2 (markedly hyperintense) were 6.9 months [6.0–8.5] for SPLEN, 9.2 months [8.3–10.7] for GENU, 10.8 months [8.1–nd] for PLIC, and 12.4 months for CR [10.2–nd]. At birth, on T2WI, PLIC and MCP in all infants had a score of +1. By 6 months, SPLEN (6.0 [5.2–7.4]) had a 90prob of score of +1. By 9 months, GENU (7.4 [6.6-9.1]), CP (7.9 [6.5-10.7]) and ALIC (8.0 [6.9-11.0) had a 90prob of +1 score. By 12 months, CR (9.8 [8.2/nd] and OWM (11.1 [10.0–nd]) had a 90prob of score of +1 score; FWM remained isointense to cortex. Age of attaining 90prob of score of +2 (moderately hypointense) were 4.2 months [3.5–9.1] for MCP, 4.3 months [3.3-7.6] for PLIC, and 8.0 months [7.1-9.4] for SPLEN.
Conclusion: Our data correlated well with those reported in a non-quantitative manner by Barkovich et al. [1] but offer the advantage of more specific dates and probability estimates for SI changes. 1. Barkovich AJ, et al. Normal maturation of the neonatal and infant brain: MR imaging at 1.5 T. Radiology 1988; 166:173-180.
249. Diffusion Imaging Assessment of Brain White Matter Maturation During the First Postnatal Year
Provenzale J. M.*; Liang L.; DeLong D.; White L. Duke University Medical Center, Durham, NC
Address correspondence to J. Provenzale (prove001{at}mc.duke.edu)
Objective: To investigate cerebral white matter (WM) maturation in first year of life in normal infants using diffusion-weighted (DW) and diffusion tensor imaging (DTI). We compared (1) apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values in deep WM and peripheral WM extrapolated to full-term from data in first 100 days of life and (2) rates of change in ADC and FA values over first year.
Materials and Methods: Fifty-three children (range: 1.5 weeks premature to 51.5 weeks) underwent DW imaging (3 directions, b = 1,000 s/mm2) and DTI with (6 directions) on a 1.5-T MR scanner. ADC and FA values were measured in 3 deep WM structures (internal capsule, genu and splenium of corpus callosum) and 2 peripheral WM regions (WM underlying prefrontal and posterior parietal cortex) using a standard ROI (44 cm2) by a single observer blinded to age. ADC and FA values were also expressed as percentage of values in same structures in a group of normal young adults. Mean ADC and FA values for deep and peripheral WM were plotted against gestational age normalized to full-term and fit best by a "broken-line" linear regression model (breakpoint at 100 days). Estimated ADC and FA values at full-term were obtained for all 5 WM regions using intercept of initial linear period with day 0. Multivariate analysis of variance tests were used to compare average age regression coefficients for deep and peripheral WM.
Results: At full-term, mean ADC value (% of adult values) in peripheral WM was 132 x 10-5 mm2/sec (163%) and deep WM was 109 x 10-5 mm2/sec (143%) (p < 0.01); mean FA value in peripheral WM was 0.16 (32%) and in deep WM was 0.36 (54%) (p < 0.01). Within first 100 days of life, slope of ADC decrease was -1.99 x 10-5 mm2/sec per week in peripheral WM and -0.94 x 10-5 mm2/sec per week in deep WM (p < 0.01). After 100 days, ADC decrease slope in peripheral WM was -0.40 x 10-5 mm2/sec/week and in deep WM was -0.38 x 10-5 mm2/sec/week (p = 0.64). In first 100 days, FA increase slope in peripheral WM was 0.005/week and in deep WM was 0.009/week (p = 0.01). After 100 days, slope of FA increase in peripheral WM was 0.002/week and in deep WM was 0.003/week (p = 0.08).
Conclusion: At full-term, ADC and FA values significantly differ in peripheral WM from deep WM, (deep WM structures more mature). ADC values in peripheral WM decreased faster during first 100 days of life, but not thereafter. The opposite pattern was seen in first 100 days for FA values; thereafter, both peripheral WM and deep WM increased at similar rates.
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