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The aim of this study was assess acute and early delayed radiation-induced changes in normal-appearing brain tissue perfusion as measured with perfusion magnetic resonance imaging (MRI) and the dependence of these changes on the fractionated radiotherapy (FRT) dose level.

Background Proximal patellar tendinopathy/jumper's knee (PT/JK) is well known to be difficult to treat. Recent studies using an ultrasound and colour Doppler-based treatment approach on the dorsal side of the tendon, sclerosing polidocanol injections and ultrasound-guided arthroscopic shaving, have shown promising clinical results. Objectives To compare the clinical effects after treatment with sclerosing polidocanol injections and arthroscopic shaving. Material and methods 52 patellar tendons (43 men and two women) with ultrasound and colour Doppler-verified diagnosis of PT/JK were randomly assigned to treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections (group A) or ultrasound and colour Doppler-guided arthroscopic shaving (group B). All patients were involved in patellar tendon loading sports or recreational activities, and had had a long duration of pain symptoms from the proximal patellar tendon. Pain during patellar tendon loading activity, and at rest, before and after treatment (visual analogue scale; VAS), and patient satisfaction with the result of the treatment, was registered. Results After treatment, the patients treated with arthroscopic shaving had a significantly lower VAS score at rest and during activity, and were significantly more satisfied compared with the patients in the sclerosing injection group. Conclusions Both treatment with ultrasound and colour Doppler-guided sclerosing polidocanol injections and arthroscopic shaving showed good clinical results, but patients treated with arthroscopic shaving had less pain and were more satisfied with the treatment result. Because surgical treatment is a one-stage treatment return to sports was faster in this group. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the effects of duration of low-load repetitive work on intramuscular lactate, pyruvate, glutamate and prostaglandin E2 (PGE2), and oxygen saturation in the trapezius muscle. Twenty healthy females were studied during baseline rest, during low-load repetitive work for either 30 (REP 30) or 60 min (REP 60) and 60 min recovery. Intramuscular microdialysate (IMMD) samples were obtained, and local muscle tissue oxygenation (%StO2) assessed with near-infrared spectroscopy (NIRS). Subjects rated their perceived exertion (Borg CR-10 scale) and capillary blood was sampled for lactate analysis. The results showed a significant increase in IMMD lactate in response to both REP 30 and REP 60 ( P < 0.05 and P < 0.01, respectively) and glutamate ( P < 0.0001), but no progressive increase with increasing work duration. Both IMMD pyruvate and lactate tended to be significantly increased during the recovery period. No corresponding increase in blood lactate was found. Local muscle %StO2 did not change significantly in response to work and was not correlated to the IMMD lactate concentration. The ratings of perceived exertion increased in response to work, and remained increased after recovery for REP 60. In conclusion, the results of this study show significantly increased IMMD lactate and, glutamate concentrations in the trapezius muscle of healthy females in response to low-load work, but no progressive increase with increased work duration. Further, they do not indicate that the increased IMMD lactate concentration was caused by a locally decreased or insufficient muscle tissue oxygenation. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the effects of duration of low-load repetitive work on intramuscular lactate, pyruvate, glutamate and prostaglandin E(2) (PGE(2)), and oxygen saturation in the trapezius muscle. Twenty healthy females were studied during baseline rest, during low-load repetitive work for either 30 (REP 30) or 60 min (REP 60) and 60 min recovery. Intramuscular microdialysate (IMMD) samples were obtained, and local muscle tissue oxygenation (%StO(2)) assessed with near-infrared spectroscopy (NIRS). Subjects rated their perceived exertion (Borg CR-10 scale) and capillary blood was sampled for lactate analysis. The results showed a significant increase in IMMD lactate in response to both REP 30 and REP 60 (P < 0.05 and P < 0.01, respectively) and glutamate (P < 0.0001), but no progressive increase with increasing work duration. Both IMMD pyruvate and lactate tended to be significantly increased during the recovery period. No corresponding increase in blood lactate was found. Local muscle %StO(2) did not change significantly in response to work and was not correlated to the IMMD lactate concentration. The ratings of perceived exertion increased in response to work, and remained increased after recovery for REP 60. In conclusion, the results of this study show significantly increased IMMD lactate and, glutamate concentrations in the trapezius muscle of healthy females in response to low-load work, but no progressive increase with increased work duration. Further, they do not indicate that the increased IMMD lactate concentration was caused by a locally decreased or insufficient muscle tissue oxygenation. [ABSTRACT FROM AUTHOR]

Diffusion kurtosis imaging (DKI) allows for assessment of diffusion influenced by microcellular structures. We analyzed DKI in suspected low-grade gliomas prior to histopathological diagnosis. The aim was to investigate if diffusion parameters in the perilesional normal-appearing white matter (NAWM) differed from contralesional white matter, and to investigate differences between glioma malignancy grades II and III and glioma subtypes (astrocytomas and oligodendrogliomas).

The purpose of this study was to investigate the prevalence and characteristics of painful conditions in the Achilles tendon region in elite badminton players. The study group consisted of 66 players in the Swedish elite division (highest level) in badminton, 41 men (mean age, 24.4 years) and 25 women (mean age, 21.9 years). Twenty-one players (32%) reported the occurrence of a disabling painful condition in the Achilles tendon region during the previous 5 years, and 11 players (17%) had an ongoing painful condition. A majority of the painful conditions (12 of 21, or 57%) were described as involving the midportion of the Achilles tendon. The players who had a painful condition reported a significantly higher weekly training load as measured by the number of hours spent in total training, badminton training, and endurance and strength training. There were no differences in age, sex, and body mass index between the players with and without painful conditions in the Achilles tendon region. [ABSTRACT FROM AUTHOR]

Objective: The most common genetic cause of amyotrophic lateral sclerosis (ALS) is the C9orf72 expansion. A high incidence of this expansion has been detected in Sweden and Finland. This Norwegian population-based study aimed to identify the prevalence, geographic distribution, ancestry, and relatedness of ALS patients with a C9orf72 expansion (C9 pos ). Further, we compared C9 pos and C9 neg patients' clinical presentation, family history of ALS and other neurodegenerative disorders, and sociodemographic status., Methods: We recruited ALS patients from all 17 Departments of neurology in Norway. Blood samples and questionnaires regarding clinical characteristics, sociodemographic status and family history of ALS, and other neurodegenerative disorders were collected. The C9orf72 expansion was examined for all patients., Results: The study enrolled 500 ALS patients, 8.8% of whom were C9 pos , with half being sporadic ALS cases. The proportion of C9 pos cases differed between regions, ranging from 17.9% in the Northern region to 1.9% in the Western region. The majority of C9 pos patients had non-Finnish European descent and were not closely related. C9 pos patients exhibited a significantly shorter mean survival time, had a higher frequency of relatives with ALS or dementia, and were more often unmarried/single and childless than C9 neg patients., Conclusion: C9 pos patients constitute a large portion of the Norwegian ALS population. Ancestry and relatedness do not adequately explain regional differences. Relying on clinical information to identify C9 pos patients has proven to be challenging. Half of C9 pos patients were reported as having sporadic ALS, underlining the importance of carefully assessing family history and the need for genetic testing.

Background: Impaired cognitive ability is one of the most frequently reported neuropsychiatric symptoms in the post-COVID phase among patients. It is unclear whether this condition is related to structural or functional brain changes., Purpose: In this study, we present a multimodal magnetic resonance imaging study of 36 post-COVID patients and 36 individually matched controls who had a mild form of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection from March 2020 to February 2022. This study aimed to investigate structural and functional brain alterations and their correlation with post-COVID symptoms and neurocognitive functions., Materials and Methods: The study protocol comprised an assessment of physical fatigue [Fatigue Severity Scale (FSS)], mental fatigue (Mental Fatigue Scale (MFS)], depression [Montgomery Asberg Depression Rating Scale (MADRS)], anxiety [Hospital Anxiety and Depression Scale (HAD)], post-COVID Symptoms Severity Score, and neurocognitive status [Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS)]. The magnetic resonance imaging protocol included morphological sequences, arterial spin labeling (ASL) and dynamic susceptibility contrast-enhanced (DSC) perfusion, diffusion tensor imaging (DTI), and resting-state functional magnetic resonance imaging (fMRI) sequences. Using these protocols, the assessments of macrostructural abnormalities, perfusion, gray matter density, white matter integrity, and brain connectivity were performed., Results: Post-COVID patients had higher levels of physical fatigue, mental fatigue, depression, and anxiety than controls and showed cognitive impairment in all the RBANS domains except in Visuospatial/Construction. The subjective mental fatigue correlated with objective impaired cognitive ability in the RBANS test, particularly in the Attention domain. There were no differences between patients and controls regarding macrostructural abnormalities, regional volumes, regional perfusion metrics, gray matter density, or DTI parameters. We observed a significant positive correlation between RBANS Total Scale Index score and gray matter volume in the right superior/middle-temporal gyrus ( p < 0.05) and a significant negative correlation between the white matter integrity and post-COVID symptoms ( p < 0.05) in the same area. The connectivity differences were observed between patients and controls in a few regions, including the right middle frontal gyrus, an important area of convergence of the dorsal and ventral attention networks. We also noted a positive correlation between post-COVID symptoms and increased connectivity in the right temporoparietal junction, which is part of the ventral attention system., Conclusion: In non-hospitalized subjects with post-COVID, we did not find any structural brain changes or changes in perfusion, compared to controls. However, we noted differences in connectivity within an important area for attention processes, which may be associated with post-COVID brain fog., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Fineschi, Fahlström, Fällmar, Haller and Wikström.)

Background: Diffuse astrocytomas preferentially infiltrate eloquent areas affecting the outcome. A preoperative understanding of isocitrate dehydrogenase (IDH) status may offer opportunities for specific targeted therapies impacting treatment management. The aim of this study was to analyze clinical, topographical, radiological in WHO 2 astrocytomas with different IDH status and the long-term patient's outcome., Methods: A series of confirmed WHO 2 astrocytoma patients (between 2005 and 2015) were retrospectively analyzed. MRI sequences (FLAIR) were used for tumor volume segmentation and to create a frequency map of their locations into the Montreal Neurological Institute (MNI) space. The Brain-Grid (BG) system (standardized radiological tool of intersected lines according to anatomical landmarks) was used as an overlay for infiltration analysis of each tumor. Long-term follow-up was used to perform a survival analysis., Results: Forty patients with confirmed IDH status (26 IDH-mutant, IDHm/14 IDH-wild type, IDHwt) according to WHO 2021 classification were included with a mean follow-up of 7.8 years. IDHm astrocytomas displayed a lower number of BG-voxels ( P < 0.05) and were preferentially located in the anterior insular region. IDHwt group displayed a posterior insular and peritrigonal location. IDHwt group displayed a shorter OS compared with IDHm ( P < 0.05), with the infiltration of 7 or more BG-voxels as an independent factor predicting a shorter OS., Conclusions: IDHm and IDHwt astrocytomas differed in preferential location, number of BG-voxels and OS at long follow-up time. The number of BG-voxels affected the OS in IDHwt was possibly reflecting higher tumor invasiveness. We encourage the systematic use of alternative observational tools, such as gradient maps and the Brain-Grid analysis, to better detect differences of tumor invasiveness in diffuse low-grade gliomas subtypes., Competing Interests: The authors report no conflict of interest., (© 2024 The Author(s). Published by Upsala Medical Society.)

Background: Paired cerebral blood flow (CBF) measurement is usually acquired before and after vasoactive stimulus to estimate cerebrovascular reserve (CVR). However, CVR may be confounded because of variations in time-to-maximum CBF response (t max ) following acetazolamide injection. With a mathematical model, CVR can be calculated insensitive to variations in t max , and a model offers the possibility to calculate additional model-derived parameters. A model that describes the temporal CBF response following a vasodilating acetazolamide injection is proposed and evaluated., Methods: A bi-exponential model was adopted and fitted to four CBF measurements acquired using arterial spin labelling before and initialised at 5, 15 and 25 min after acetazolamide injection in a total of fifteen patients with Moyamoya disease. Curve fitting was performed using a non-linear least squares method with a priori constraints based on simulations., Results: Goodness of fit (mean absolute error) varied between 0.30 and 0.62 ml·100 g -1 ·min -1 . Model-derived CVR was significantly higher compared to static CVR measures. Maximum CBF increase occurred earlier in healthy- compared to diseased vascular regions., Conclusions: The proposed mathematical model offers the possibility to calculate CVR insensitive to variations in time to maximum CBF response which gives a more detailed characterisation of CVR compared to static CVR measures. Although the mathematical model adapts generally well to this dataset of patients with MMD it should be considered as experimental; hence, further studies in healthy populations and other patient cohorts are warranted., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Genetic repeat expansions cause neuronal degeneration in amyotrophic lateral sclerosis as well as other neurodegenerative disorders such as spinocerebellar ataxia, Huntington's disease and Kennedy's disease. Repeat expansions in the same gene can cause multiple clinical phenotypes. We aimed to characterize repeat expansions in a Norwegian amyotrophic lateral sclerosis cohort. Norwegian amyotrophic lateral sclerosis patients ( n = 414) and neurologically healthy controls adjusted for age and gender ( n = 713) were investigated for repeat expansions in AR , ATXN1 , ATXN2 and HTT using short read exome sequencing and the ExpansionHunter software. Five amyotrophic lateral sclerosis patients (1.2%) and two controls (0.3%) carried ≥36 repeats in HTT ( P = 0.032), and seven amyotrophic lateral sclerosis patients (1.7%) and three controls (0.4%) carried ≥29 repeats in ATXN2 ( P = 0.038). One male diagnosed with amyotrophic lateral sclerosis carried a pathogenic repeat expansion in AR , and his diagnosis was revised to Kennedy's disease. In ATXN1 , 50 amyotrophic lateral sclerosis patients (12.1%) and 96 controls (13.5%) carried ≥33 repeats ( P = 0.753). None of the patients with repeat expansions in ATXN2 or HTT had signs of Huntington's disease or spinocerebellar ataxia type 2, based on a re-evaluation of medical records. The diagnosis of amyotrophic lateral sclerosis was confirmed in all patients, with the exception of one patient who had primary lateral sclerosis. Our findings indicate that repeat expansions in HTT and ATXN2 are associated with increased likelihood of developing amyotrophic lateral sclerosis. Further studies are required to investigate the potential relationship between HTT repeat expansions and amyotrophic lateral sclerosis., Competing Interests: The authors report no competing interests., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Guarantors of Brain.)

Background: Grade 2-3 diffuse gliomas (DGs) show extensive infiltration through white matter (WM) tracts. Along-tract analysis of WM tracts based on diffusion tensor tractography (DTI) can been performed to assess the microstructural integrity of WM tracts. The clinical implication of these DTI-related findings is still under debate, especially in tumor patients. The aim of this study was to analyze and compare diffusion-based parameters along WM tracts and variables specific to WM -tumor interactions in DGs and correlate them with preoperative neuropsychological assessment., Methods: Fourteen patients with IDH-mutated grade 2-3 DGs were included. Tumor volumes were manually segmented on 3D-FLAIR images after spatial normalisation to MNI space. DTI was acquired using a single-shot echo-planar sequence on a 3T with 48 sampling directions. DTI data were reconstructed within the MNI space using q-space diffeomorphic reconstruction (QSDR) in DSI studio. Five bilateral sets of WM tracts were reconstructed based on the HCP-1065 template. All WM tracts were stretched to the same length of 100 indices, and for each index diffusion-based parameters fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity (AD), mean diffusivity (MD) and quantitative anisotropy (QA) were sampled. Tumor-related parameters (TRP); tumor volume (Tv), maximum tumor presence (MTP) and the number of sequential indices in which a tumor is present (Te) were derived based on the along-tract analysis. Normal data were constructed by calculating the average and standard deviations of contralateral and not-affected WM tracts for each diffusion-based parameter, respectively. Affected WM tracts were individually compared to normal data using a z-test. Preoperative neuropsychological assessment was performed in all subjects and correlated to results from the along-tract analysis using correlation and logistic regression models., Results: Abnormalities in diffusion-based parameters were detected in WM tracts. Topographical and quantitative information were presented within the same graph. AD and MD displayed the highest linear correlation with the TRPs. Abnormal QA showed a linear correlation with Tv per WM tract. Neuropsychological impairment was correlated with all the TRPs and with abnormal FA ( p < 0.05) and abnormal QA ( p < 0.01). Abnormal QA was the only independent variable able to predict the presence of neuropsychological impairment in the patients based on the linear regression analysis., Conclusions: Graphical presentation of the along-tract analysis presented in this study shows that it may be a sensitive and robust method to acquire and display topographical and qualitative information regarding WM tracts in close proximity to DGs. Further studies and refinements to the methods presented herein may advance current clinical methods for evaluating displacement and infiltrations and further aid the efforts of pre-planning surgical interventions with the goal to maximise EOR and tailor oncological treatment.

Objective: To explore the experiences of acculturation into secular Swedish society of former members of cults, with particular focus on mental health, needs and resources., Design: Qualitative method using the Cultural Formulation Interview (CFI) from the DSM-5 as an interview guide. Analysis of participants' experiences of acculturation through systematic text condensation., Participants: Eleven Swedish former members of ideological or religion-based cults., Setting: Swedish mainstream, secular society., Results: Former cult members experience an 'in-between time' in the period after leaving the cult and find themselves in a confusing, chaotic state. They describe having lived in an honor culture where acts of violence were normalized. In the cult, they felt disconnected from themselves, and post-cult they try to regain access to their own values and feelings as well as create new bonds with family members and friends outside the cult. They find it hard to talk about their cult background and find relief in communicating with other former cult members. In their post-cult life, they eventually start seeing the world in a brighter, more hopeful way than before. However, they are also at risk of re-experiencing cult-related traumatic events and of new traumatic experiences within the post-cult acculturation process, and of persistent psychological distress., Conclusion: Former cult members face a challenging acculturation process, having lost a functioning worldview upon leaving the cult but not yet gained another to take its place. While the in-between time is often transient, they may need support from the healthcare system, especially regarding mental health concerns, while establishing themselves into mainstream society., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hadding, Semb, Lehti, Fahlström, Sandlund and DeMarinis.)

Purpose: Moyamoya (MM) disease is characterized by progressive intracranial arterial stenosis. Patients commonly need revascularization surgery to optimize cerebral blood flow (CBF). Estimation of CBF and cerebrovascular reserve (CVR) is therefore necessary before and after surgery. However, assessment of CBF before and after indirect revascularization surgery with the multiple burr hole (MBH) technique in MM has not been studied extensively. In this study, we describe our initial experience using arterial spin labeling magnetic resonance perfusion imaging (ASL-MRI) for CBF and CVR assessment before and after indirect MBH revascularization surgery in MM patients., Methods: Eleven MM patients (initial age 6-50 years, 1 male/10 female) with 19 affected hemispheres were included. A total of 35 ASL-MRI examinations were performed using a 3D-pCASL acquisition before and after i.v. acetazolamide challenge (1000 mg in adults and 10 mg/kg in children). Twelve MBH procedures were performed in seven patients. The first follow-up ASL-MRI was performed 7-21 (mean 12) months after surgery., Results: Before surgery, CBF was 46 ± 16 (mean ± SD) ml/100 g/min and CVR after acetazolamide challenge was 38.5 ± 9.9 (mean ± SD)% in the most affected territory (middle cerebral artery). In cases in which surgery was not performed, CVR was 56 ± 12 (mean ± SD)% in affected hemispheres. After MBH surgery, there was a relative change in CVR compared to baseline (preop) of + 23.5 ± 23.3% (mean ± SD). There were no new ischemic events., Conclusion: Using ASL-MRI we followed changes in CBF and CVR in patients with MM. The technique was encouraging for assessments before and after revascularization surgery., (© 2023. The Author(s).)

Background: Cerebral hemodynamics in moyamoya disease (MMD) is complex and needs further elucidation. The primary aim of the study was to determine the association of the cerebrovascular reserve (CVR) with cerebral blood flow (CBF) disturbances, oxygen extraction fraction (OEF max ), and energy metabolism ( CMRO 2 max ) in MMD, using arterial spin label magnetic resonance imaging (ASL-MRI) before and after acetazolamide administration., Methods: Thirty-nine ASL-MRI scans with a concurrent acetazolamide challenge from 16 MMD patients at the Uppsala University Hospital, Sweden, 2016-2021, were retrospectively analyzed. CBF was assessed before and 5, 15, and 25 min after acetazolamide administration, and the maximal response CVR max was used for further analyses. Dynamic susceptibility contrast (DSC) MRI was performed 30 min after acetazolamide injection, and the data were analyzed using the Cercare Medical Neurosuite to assess capillary transit time heterogeneity (CTTH; indicating microvascular function), OEF max , and CMRO 2 max ., Results: In the ACA territory, a lower CVR max was associated with lower baseline CBF, higher CTTH, and higher OEF max but not with CMRO 2 max in generalized estimating equation models. In the MCA territory, lower CVR max was associated with lower baseline CBF and higher CMRO 2 max but not with CTTH and OEF max. ., Conclusion: Altogether, a compromised CVR in MMD patients reflected disturbances in macro-/microvascular blood flow, oxygenation, and CMRO 2 . ASL-MRI with acetazolamide challenge is a feasible and radiation-free alternative to positron emission tomography (PET) imaging in MMD., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Svedung Wettervik, Fahlström, Wikström, Lewén and Enblad.)

Introduction: Single-delay Arterial Spin Labeling (ASL)-based spatial coefficient of variation (CoV CBF ) has been suggested as a measure of hemodynamic disturbance in patients with cerebrovascular diseases. However, spatial CoV CBF and other histogram-based parameters such as skewness and kurtosis and the volume of the arterial transit time artefact (ATA vol ), has not been evaluated in patients with MMD nor against cerebrovascular reserve (CVR). The aim of this study was to assess whether any associations between spatial CoV CBF , skewness, kurtosis, and ATA vol are present and to analyze any potential associations with CVR, derived from single-delay ASL in patients with MMD., Methods: Fifteen MMD patients were included before or after revascularization surgery. Cerebral blood flow (CBF) maps were acquired using pseudo-continuous ASL before, and 5, 15, and 25 min after an intravenous acetazolamide injection. CVR max was defined as the highest percentual increase in CBF at any of the three post-injection time points. A vascular territory template was spatially normalized to each patient, including the bilateral anterior, middle, and posterior cerebral arteries. All affected anterior and middle cerebral artery regions and all unaffected posterior cerebral artery regions were included, based on Suzuki grading by digital subtraction angiography., Results: Significant differences between affected and unaffected regions were found for CBF, CVR max , and ATA vol . No association was found between CVR max and any other parameter. High correlations were found between spatial CoV CBF , skewness and ATA vol ., Conclusion: Spatial CoV CBF derived from single-delay ASL does not correlate with CVR in patients with MMD. Moreover, skewness and kurtosis did not provide additional information of clinical value., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Fahlström, Svedung Wettervik, Enblad, Lewén and Wikström.)

Empathy in the doctor-patient relationship is of great importance and has long been considered a true professional virtue for doctors. Despite the general agreement concerning the importance of empathy, there is no consensus regarding the definition of empathy in medical research. While several quantitative studies, measuring empathy as an individual trait, show a decline in empathy among medical students, other studies have shown that empathy is influenced by contextual factors as well as the availability of role models. Therefore, further studies about the transition from medical school to clinical work also including the perspective of senior doctors are needed. The study presented in this article aims to better understand the clinical conditions for empathy through interviews with senior doctors about their lived experience of empathy. Twelve senior doctors, from different specialities were interviewed using a semi-structured approach. The data was analysed using content analysis. The analysis resulted in the main theme: Empathy as a silent art-a doctor`s daily balancing act. This main theme comprised three categories: "A tacit, yet language-dependent process", "A daily balancing act" and "An unsupported path towards mastery". Doctors face many challenges in their daily balancing act between individual and structural conditions that may affect empathy. In order to maintain and further develop empathy, doctors need working conditions allowing for collegial reflection and conversations that promote empathy., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 von Knorring et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Stroke caused by dissection of arteries of the vertebrobasilar system in children is still poorly investigated in terms of etiology, means of treatment, course of disease, and prognosis. The aim of this report was to describe the unusual course of a spontaneous dissection of the basilar artery (BA) in a child treated with endovascular techniques and to point out that the plasticity of the brain stem can fully compensate for structural damage caused by stroke. We report the case of a 15-year-old boy who suffered a wake-up stroke with BA occlusion caused by spontaneous dissection. A blood clot was aspirated from the false lumen and the true lumen re-opened, but the patient deteriorated a few hours later, and repeated angiography revealed that the intimal flap was detached, occluding the BA again. The lumen of BA was then reconstructed by a stent. Despite a large pons infarction, the patient was completely recovered 11 months after the onset. The case was analyzed with angiograms and magnetic resonance imaging, macroscopic and microscopic pathological analysis, computed tomographic angiography, magnetic resonance-based angiography, and diffusion tensor imaging. This case illustrates that applied endovascular techniques and intensive care measures can alter the course of potentially fatal brain stem infarction. Our multimodal analysis gives new insight into the anatomical basis for the plasticity mechanism of the brain stem., (© 2021. The Author(s).)

Primary Objective: Traumatic brain injury (TBI) and sports-related concussion (SRC) may result in chronic functional and neuroanatomical changes. We tested the hypothesis that neuroimaging findings (cerebral blood flow (CBF), cortical thickness, and 1 H-magnetic resonance (MR) spectroscopy (MRS)) were associated to cognitive function, TBI severity, and sex., Research Design: Eleven controls, 12 athletes symptomatic following ≥3SRCs and 6 patients with moderate-severe TBI underwent MR scanning for evaluation of cortical thickness, brain metabolites (MRS), and CBF using pseudo-continuous arterial spin labeling (ASL). Cognitive screening was performed using the RBANS cognitive test battery., Main Outcomes and Results: RBANS-index was impaired in both injury groups and correlated with the injury severity, although not with any neuroimaging parameter. Cortical thickness correlated with injury severity (p = 0.02), while neuronal density, using the MRS marker ((NAA+NAAG)/Cr, did not. On multivariate analysis, injury severity (p = 0.0003) and sex (p = 0.002) were associated with CBF. Patients with TBI had decreased gray (p = 0.02) and white matter (p = 0.02) CBF compared to controls. CBF was significantly lower in total gray, white matter and in 16 of the 20 gray matter brain regions in female but not male athletes when compared to female and male controls, respectively., Conclusions: Injury severity correlated with CBF, cognitive function, and cortical thickness. CBF also correlated with sex and was reduced in female, not male, athletes. Chronic CBF changes may contribute to the persistent injury mechanisms in TBI and rSRC.

Background: Neurological and psychiatric manifestations related to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection are widely recognised. Standard magnetic resonance imaging (MRI) investigations are normal in 40-80% of symptomatic patients, eventually delaying appropriate treatment when MRI is unrevealing any structural changes. The aim of this study is to investigate white matter abnormalities during an early stage of post-COVID-19 (coronavirus disease 2019) encephalitis while conventional MRI was normal., Methods: A patient with post-COVID-19 autoimmune encephalitis was investigated by serial MRIs and diffusion tensor imaging (DTI). Ten healthy control individuals (HC) were utilised as a control group for the DTI analysis. Major projection, commissural and association white matter pathways were reconstructed, and multiple diffusion parameters were analysed and then compared to the HC average using a z-test for serial examinations., Results: Eleven days after the onset of neurological symptoms, DTI revealed early white matter changes, compared with HC, when standard MRI was normal. On day 68, DTI showed multiple white matter lesions compared with HC, visible at this time also by the MRI images, indicating inflammatory changes in different association and projection white matter pathways., Conclusion: We confirm a limitation in the sensitivity of conventional MRI at the acute setting of post-COVID-19 autoimmune encephalitis. A complementary DTI investigation could be a valuable diagnostic tool in early therapeutic decisions concerning COVID-19-related neurological symptoms., Competing Interests: The authors report no conflict of interest., (© 2022 The Author(s). Published by Upsala Medical Society.)