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Biomedical subjects

Siegfried Trattnig

Publications and source records attributed to Siegfried Trattnig.

At least 19 recordsLinked to original sources

High-field magnetic resonance imaging of meniscoids in the zygapophyseal joints of the human cervical spine.

STUDY DESIGN: Prospective in vitro study of meniscoids in the cervical zygapophysial joints. OBJECTIVES.: To assess the use of high-field magnetic resonance imaging (MRI) as a potential tool for evaluating meniscoids of the cervical zygapophysial joints. SUMMARY OF BACKGROUND DATA: Pain originating from the cervical spine is a frequent condition. It has been suggested that pathologic conditions of meniscoids within the zygapophysial joints may cause pain. METHODS: Six zygapophysial joints from one embalmed human body were investigated with a 3.0-T MR unit, equipped with a microimaging-set. MRIs were correlated with microanatomical sections. RESULTS: High-quality images of the meniscoids were obtained for all joints examined. There was a good correlation between the anatomic features derived from MRI and the microanatomical sections. CONCLUSIONS: High-field MRI was successfully implemented as a noninvasive method for imaging the meniscoids in cervical zygapophysial joints. The results of this in vitro study indicate that high-field MRI may be feasible in evaluating patients with cervical pain possibly related to meniscoid pathology.

Anatomy, Cross-Sectional↗

Quantitative and topographical evaluation of ankle articular cartilage using high resolution MRI.

The objectives of this study were to quantitatively evaluate the articular cartilage layers of the ankle and describe the cartilage topographical distribution across the joint surfaces using high resolution MRI and image segmentation. An anisotropic diffusion noise reduction algorithm and a directional gradient vector flow (dGVF) snake segmentation algorithm were applied to cartilage sensitive MR images. Eight cadaveric ankles were studied. Six repeated data sets were acquired in five of the ankles. Quantitative parameters were calculated for each cartilage layer; coefficients of variation (CV) were calculated from the six repeated data sets; and 3D thickness distribution maps were generated. The noise reduction algorithm produced marked image enhancement. Mean cartilage thickness ranged from 0.91 +/- 0.08 mm in the fibula to 1.34 +/- 0.14 mm in the talus. Mean cartilage volume was 3.32 +/- 0.55 ml, 1.72 +/- 0.25 ml, and 0.35 +/- 0.06 ml for the talus, tibia, and fibula, respectively. Mean CV ranged 2.82%-5.04% for quantitative parameters in the talus and tibia. The reported noise reduction and segmentation technique allow precise extraction of ankle cartilage and 3D reconstructions show that the thickest cartilage occurs over the talar shoulders, where osteochondritits dissecans (OCD) lesions commonly occur.

Algorithms↗

Comparison of fMRI coregistration results between human experts and software solutions in patients and healthy subjects.

Functional magnetic resonance imaging (fMRI) performed by echo-planar imaging (EPI) is often highly distorted, and it is therefore necessary to coregister the functional to undistorted anatomical images, especially for clinical applications. This pilot study provides an evaluation of human and automatic coregistration results in the human motor cortex of normal and pathological brains. Ten healthy right-handed subjects and ten right-handed patients performed simple right hand movements during fMRI. A reference point chosen at a characteristic anatomical location within the fMRI sensorimotor activations was transferred to the high resolution anatomical MRI images by three human fMRI experts and by three automatic coregistration programs. The 3D distance between the median localizations of experts and programs was calculated and compared between patients and healthy subjects. Results show that fMRI localization on anatomical images was better with the experts than software in 70% of the cases and that software performance was worse for patients than healthy subjects (unpaired t-test: P = 0.040). With 45.6 mm the maximum disagreement between experts and software was quite large. The inter-rater consistency was better for the fMRI experts compared to the coregistration programs (ANOVA: P = 0.003). We conclude that results of automatic coregistration should be evaluated carefully, especially in case of clinical application.

Adolescent↗

The optimal use of contrast agents at high field MRI.

The intravenous administration of a standard dose of conventional gadolinium-based contrast agents produces higher contrast between the tumor and normal brain at 3.0 Tesla (T) than at 1.5 T, which allows reducing the dose to half of the standard one to produce similar contrast at 3.0 T compared to 1.5 T. The assessment of cumulative triple-dose 3.0 T images obtained the best results in the detection of brain metastases compared to other sequences. The contrast agent dose for dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging at 3.0 T can be reduced to 0.1 mmol compared to 0.2 mmol at 1.5 T due to the increased susceptibility effects at higher magnetic field strengths. Contrast agent application makes susceptibility-weighted imaging (SWI) at 3.0 T clinically attractive, with an increase in spatial resolution within the same scan time. Whereas a double dose of conventional gadolinium-based contrast agents was optimal in SWI with respect to sensitivity and image quality, a standard dose of gadobenate dimeglumine, which has a two-fold higher T1-relaxivity in blood, produced the same effect. For MR-arthrography, optimized concentrations of gadolinium-based contrast agents are similar at 3.0 and 1.5 T. In summary, high field MRI requires the optimization of the contrast agent dose in different clinical applications.

Brain↗

Are cerebral cavernomas truly nonenhancing lesions and thereby distinguishable from arteriovenous malformations? MRI findings and histopathological correlation.

PURPOSE: The aim of this study was to determine whether cerebral cavernomas are truly nonenhancing lesions on magnetic resonance imaging (MRI), whether they can be distinguished from arteriovenous malformations (AVM) on that basis and to evaluate the incidence of their association with developmental venous anomalies (DVA). PATIENTS AND METHODS: Thirty-two patients who underwent neurosurgical operation for a cerebral vascular malformation and had a standard MRI conclusive of cerebral cavernoma were retrospectively evaluated for size of the lesions, contrast enhancement of the lesion and the coexistence of DVA. The contrast uptake of these lesions was investigated, and contrast enhancement was classified as none, moderate or marked. The incidence of an associated DVA was also investigated. The radiological findings were subsequently correlated with neurohistopathological findings. RESULTS: No difference was found between the contrast enhancement of cavernomas and AVMs. Cross tables were calculated for contrast enhancement and size, which demonstrated no statistically significant correlation. Cross tables were calculated for contrast enhancement and histopathological diagnosis, which revealed that both entities presented variable degrees of contrast enhancement and were thereby not distinguishable from each other on the basis of contrast enhancement. We found an association of cavernoma with DVA in 30% of cases. CONCLUSION: Neither a correlation between the absence of contrast enhancement and the histopathological diagnosis of cavernoma nor the size and contrast enhancement was found. We conclude that cavernomas present with variable degrees of contrast enhancement on MRI and, thus, are definitely not distinguishable from AVM on the basis of contrast enhanced MRI. We found an association between cavernomas and DVA in approximately one third of patients.

Adolescent↗

Contrast-enhanced, high-resolution, susceptibility-weighted magnetic resonance imaging of the brain: dose-dependent optimization at 3 tesla and 1.5 tesla in healthy volunteers.

OBJECTIVES: We sought to determine the optimal dose of a contrast agent with known high relaxivity on 1.5 and 3 Tesla scanners that would achieve the best compromise between image quality and scan time for the clinical application of contrast-enhanced susceptibility-weighted imaging (CE-SWI). METHODS: Pre- and postcontrast SWI was performed with different contrast agent doses (0.05, 0.1, and 0.2 mmol/kg gadobenate dimeglumine) at both 1.5 and 3 T in 6 healthy volunteers, resulting in 72 examinations. Venograms were created from minimum intensity projection reconstructions over specified deep white matter volumes to enhance the visual appearance of connected venous structures. Three independent radiologists blindly rated the visibility of the veins on a continuous scale of 1 to 10. A general linear model was used for statistical evaluation, with fixed effects of the contrast agent dose, the field strength, the rater and the patients as a random effect. RESULTS: With CE-SWI, we found significant differences in the visibility of the deep veins dependent on the contrast media dose (P=0.02). At 3 T, the visibility of deep venous vessels, with regard to susceptibility effect, image quality, and scan time reduction after a standard contrast agent dose 0.1 mmol/kg was significantly better than that achieved with 0.05 mmol/kg. The visibility was considered equal with 0.1 mmol/kg of the contrast agent to the precontrast images and a dose of 0.2 mmol/kg. At 1.5 T, no significant difference was found between the 4 contrast agent doses. We found no difference in the visibility of the veins with the shorter sequences at 3 T compared with the sequences at 1.5 T. CONCLUSIONS: Only a standard dose (0.1 mmol/kg) of gadobenate dimeglumine is required to achieve the optimum susceptibility effect and image quality at 3 T, together with a reduced scan time. This result can be attributed to the higher relaxivity of gadobenate dimeglumine, compared with conventional gadolinium chelates.

Adult↗

Impairment of chondrocyte biosynthetic activity by exposure to 3-tesla high-field magnetic resonance imaging is temporary.

The influence of magnetic resonance imaging (MRI) devices at high field strengths on living tissues is unknown. We investigated the effects of a 3-tesla electromagnetic field (EMF) on the biosynthetic activity of bovine articular cartilage. Bovine articular cartilage was obtained from juvenile and adult animals. Whole joints or cartilage explants were subjected to a pulsed 3-tesla EMF; controls were left unexposed. Synthesis of sulfated glycosaminoglycans (sGAGs) was measured by using [35S]sulfate incorporation; mRNA encoding the cartilage markers aggrecan and type II collagen, as well as IL-1beta, were analyzed by RT-PCR. Furthermore, effects of the 3-tesla EMF were determined over the course of time directly after exposure (day 0) and at days 3 and 6. In addition, the influence of a 1.5-tesla EMF on cartilage sGAG synthesis was evaluated. Chondrocyte cell death was assessed by staining with Annexin V and TdT-mediated dUTP nick end labelling (TUNEL). Exposure to the EMF resulted in a significant decrease in cartilage macromolecule synthesis. Gene expression of both aggrecan and IL-1beta, but not of collagen type II, was reduced in comparison with controls. Staining with Annexin V and TUNEL revealed no evidence of cell death. Interestingly, chondrocytes regained their biosynthetic activity within 3 days after exposure, as shown by proteoglycan synthesis rate and mRNA expression levels. Cartilage samples exposed to a 1.5-tesla EMF remained unaffected. Although MRI devices with a field strength of more than 1.5 T provide a better signal-to-noise ratio and thereby higher spatial resolution, their high field strength impairs the biosynthetic activity of articular chondrocytes in vitro. Although this decrease in biosynthetic activity seems to be transient, articular cartilage exposed to high-energy EMF may become vulnerable to damage.

Aggrecans↗

Magnetic resonance observation of cartilage repair tissue (MOCART) for the evaluation of autologous chondrocyte transplantation: determination of interobserver variability and correlation to clinical outcome after 2 years.

In an observational study, the validity and reliability of magnetic resonance imaging (MRI) for the assessment of autologous chondrocyte transplantation (ACT) in the knee joint was determined. Two years after implantation, high-resolution MRI was used to analyze the repair tissue with nine pertinent variables. A complete filling of the defect was found in 61.5%, and a complete integration of the border zone to the adjacent cartilage in 76.9%. An intact subchondral lamina was present in 84.6% and an intact subchondral bone was present in 61.5%. Isointense signal intensities of the repair tissue compared to the adjacent native cartilage were seen in 92.3%. To evaluate interobserver variability, a reliability analysis with the determination of the intraclass correlation coefficient (ICC) was calculated. An "almost perfect" agreement, with an ICC value >0.81, was calculated in 8 of 9 variables. The clinical outcome after 2 years showed the visual analog score (VAS) at 2.62 (S.D. +/-0.65). The values for the knee injury and osteoarthritis outcome score (KOOS) subgroups were 68.29 (+/-23.90) for pain, 62.09 (+/-14.62) for symptoms, 75.45 (+/-21.91) for ADL function, 52.69 (+/-28.77) for sport and 70.19 (+/-22.41) for knee-related quality of life. The clinical scores were correlated with the MRI variables. A statistically significant correlation was found for the variables "filling of the defect," "structure of the repair tissue," "changes in the subchondral bone," and "signal intensities of the repair issue". High resolution MRI and well-defined MRI variables are a reliable, reproducible and accurate tool for assessing cartilage repair tissue.

Adult↗

Matrix-based autologous chondrocyte implantation for cartilage repair: noninvasive monitoring by high-resolution magnetic resonance imaging.

OBJECTIVE: Monitoring of articular cartilage repair after matrix-associated autologous chondrocyte implantation (MACI) by a new grading and point-scale system based on noninvasive cartilage-specific magnetic resonance imaging (MRI) protocol. PATIENTS AND METHODS: In 20 patients, postoperative high-resolution MRI follow-up examinations at 4, 12, 24 and 52 weeks after matrix-based ACI for cartilage repair were initiated. The repair tissue was described with separate variables: degree of defect repair in width and length, surface, structure and signal intensity of the repair tissue, and status of the subchondral lamina and bone. For these variables, a grading system with point-scale evaluation was applied, and the mean average values were calculated for every follow-up MR exam of each patient. RESULTS: In 10 patients, an incomplete filling of the defect improved to complete filling (6 patients) or less incomplete (4 patients) filling of the defect. Three cases of implant hypertrophy returned to normal within 1 year. Complete filling of the defect by repair tissue was found in 2 patients from the beginning. Integration was complete in 10 cases. Improvement of incomplete to complete integration was found in 3 patients. The signal intensity of the implant developed to native cartilage signal in 13 patients. The mean average values increased from the 4th to the 52 nd week in 17 of 20 patients and decreased in 3 of 20 patients. CONCLUSION: High-resolution MRI provides a noninvasive tool for monitoring the development of cartilage repair tissue in MACI over time and helps to differentiate abnormal repair tissue from a normal maturation process.

Adult↗

White matter hyperintensities and chronicity of depression.

OBJECTIVE: White matter hyperintensities (WMHs) on T(2)-weighted magnetic resonance imaging (MRI) of the brain are associated with advanced age and late-life depression. Most investigations predominantly found these lesions in frontal lobe and basal ganglia supporting the hypothesis of a fronto-striatal dysfunction in depression. A prospective study was undertaken to investigate the association between extent of WMHs and clinical outcome in elderly depressed patients. METHODS: Thirty-one non-demented depressed subjects underwent a 1.5 T cranial MRI scan. The MRI scans were analysed in consensus by two experienced radiologists. Each MRI scan was assessed for presence and extent of WMHs, which are differentiated in periventricular hyperintensities (PVHs) and deep white matter hyperintensities (DWMHs). A total of 21 patients of the original cohort of 31 patients were re-assessed 5 years after baseline assessment. We ascertained the severity of depressive symptoms, the longitudinal course of depression, the cognitive decline and the global assessment of functioning at follow-up visit. RESULTS: (1) Subjects with greater extent of WMHs had a significant higher Hamilton Depression Rating Scale (HAM-D) score, (2) had more severe longitudinal courses of depression (3) and had a lower Mini-Mental State Examination (MMSE) score. CONCLUSIONS: WMHs on MRI are associated with poorer outcome in elderly depressed subjects. Further studies are needed to evaluate WHMs as prognostic factor for an appropriate treatment decision-making.

Aged↗

Contrast-enhanced high-resolution magnetic resonance imaging of autologous cartilage implants of the knee joint.

Over the past decade, a number of interventions for durable cartilage repair have emerged. Magnetic resonance (MR) tomography is an excellent noninvasive method for monitoring cartilage repair tissues throughout the postsurgical period. However, evaluating cartilage morphology after matrix-based autologous cartilage implantation (ACI) with MR imaging (MRI) still remains a challenge. In this study, we combined a high-resolution cartilage-sensitive fast-spin echo (FSE) sequence with intravenous application of a contrast agent for enhancing synovial fluid. Two independent musculoskeletal radiologists interpreted the pictures for the thickness, length and surface of the cartilage implants. A multivariate two-way analysis of variance with two repeated measures was performed and showed that evaluation of cartilage implant morphology was significantly improved after the application of gadodiamide on proton density FSE images. Contrast-enhanced MRI of articular cartilages is a promising technique in the postoperative follow-up of patients after ACI.

Adult↗

Early postoperative adherence of matrix-induced autologous chondrocyte implantation for the treatment of full-thickness cartilage defects of the femoral condyle.

Matrix-induced autologous chondrocyte implantation (MACI) is a tissue-engineering technique for the treatment of full-thickness articular cartilage defects and requires the use of a three-dimensional collagen type I-III membrane seeded with cultured autologous chondrocytes. The cell-scaffold construct is implanted in the debrided cartilage defect and fixed only with fibrin glue, with no periosteal cover or further surgical fixation. In a clinical pilot study, the MACI technique was used for the treatment of full-thickness, weight-bearing chondral defects of the femoral condyle in 16 patients. All patients were followed prospectively and the early postoperative attachment rate, 34.7 days (range: 22-47) after the scaffold implantation, was determined. With the use of high-resolution magnetic resonance imaging (MRI), the transplant was graded as completely attached, partially attached, or detached. In 14 of 16 patients (87.5%), a completely-attached graft was found, and the cartilage defect site was totally covered by the implanted scaffold and repair tissue. In one patient (6.25%), a partial attachment occurred with partial filling of the chondral defect. A complete detachment of the graft was found in one patient (6.25%), which resulted in an empty defect site with exposure of the subchondral bone. Interobserver variability for the MRI grading of the transplants showed substantial agreement (kappa=0.775) and perfect agreement (kappa(w)=0.99). In conclusion, the implantation and fixation of a cell-scaffold construct in a deep cartilage defect of the femoral condyle with fibrin glue and with no further surgical fixation leads to a high attachment rate 34.7 days after the implantation, as determined with high resolution MRI.

Adult↗

Definition of pertinent parameters for the evaluation of articular cartilage repair tissue with high-resolution magnetic resonance imaging.

To evaluate articular cartilage repair tissue after biological cartilage repair, we propose a new technique of non-invasive, high-resolution magnetic resonance imaging (MRI) and define a new classification system. For the definition of pertinent variables the repair tissue of 45 patients treated with three different techniques for cartilage repair (microfracture, autologous osteochondral transplantation, and autologous chondrocyte transplantation) was analyzed 6 and 12 months after the procedure. High-resolution imaging was obtained with a surface phased array coil placed over the knee compartment of interest and adapted sequences were used on a 1 T MRI scanner. The analysis of the repair tissue included the definition and rating of nine pertinent variables: the degree of filling of the defect, the integration to the border zone, the description of the surface and structure, the signal intensity, the status of the subchondral lamina and subchondral bone, the appearance of adhesions and the presence of synovitis. High-resolution MRI, using a surface phased array coil and specific sequences, can be used on every standard 1 or 1.5 T MRI scanner according to the in-house standard protocols for knee imaging in patients who have had cartilage repair procedures without substantially prolonging the total imaging time. The new classification and grading system allows a subtle description and suitable assessment of the articular cartilage repair tissue.

Adult↗

Dynamic contrast-enhanced MR imaging of the stimulated pituitary gland.

Apoplexy due to infarction and/or hemorrhage is a frequent complication of pituitary adenoma, occurring either spontaneously or precipitated by several factors, among them pituitary function test with hypothalamic releasing hormones. The mechanism by which releasing hormones cause pituitary apoplexy is unclear. It has been proposed that increase in pituitary size and/or alterations in blood flow could be responsible. The aim of this study was to explore the effects of intravenous administration of hypothalamic releasing hormones on pituitary size and hemodynamics in healthy subjects. Gadolinium-DTPA-enhanced dynamic magnetic resonance imaging (MRI) was performed in eight healthy volunteers under basal conditions and 20 min after injection of releasing hormones. Mean upslopes of Gadolinium-DTPA enhancement curves showed good correlation between basal and stimulated conditions (R = 0.89) and were significantly steeper after stimulation (P = 0.017). In contrast, pituitary height, width and length did not differ significantly between basal and stimulated conditions. In conclusion, the pituitary does not swell in healthy subjects in response to stimulation with hypothalamic releasing hormones, whereas transfer of contrast agent to tissue (blood flow and/or vessel permeability) is enhanced.

Adenoma↗

Application of three-tesla magnetic resonance imaging for diagnosis and surgery of sellar lesions.

OBJECT: The aim of this study was to determine the value of high-field magnetic resonance (MR) imaging for diagnosis and surgery of sellar lesions. METHODS: High-field MR images were obtained using a 3-tesla unit with emphasis on sellar and parasellar structures in 21 patients preoperatively to delineate endo-, supra-, and parasellar anatomical structures. Special attention was given to the medial border of the cavernous sinus and possible invasion of a sellar tumor therein, and to assessing the application of high-resolution images during intraoperative neuronavigation. The 3-tesla MR images were compared with the standard MR images already obtained and with intraoperative findings. Anatomical structures were studied in all 42 cavernous sinuses; in 32 of them comparisons with intraoperative findings were possible. The medial cavernous sinus border was rated intact in 53% on standard MR images, in 72% on 3-tesla MR images, and in 81% intraoperatively. With a positive correlation to surgical findings on 84% of 3-tesla MR images compared with 59% of standard MR images, a sensitivity of 83% compared with 67%, and a specificity of 84% compared with 58% (p = 0.016, McNemar test), 3-tesla MR imaging was superior for predicting tumor invasion through the medial cavernous sinus border. Although no difference was noted in delineation of the medial, superior, and inferior compartments, there was a better delineation of the lateral cavernous sinus compartment with 3-tesla MR imaging. This compartment was clearly visible on 40 sides (95%) on 3-tesla MR images compared with 34 sides (81%) on standard MR images. Identification of the cavernous sinus segments of the third, fourth, fifth (V1 and V2), and sixth cranial nerves was improved using high-resolution 3-tesla imaging compared with standard MR imaging. A mean of four cranial nerves was found as hypointense spots (range two-five spots) on 3-tesla MR imaging compared with a mean of three (range zero-four spots) on standard MR imaging. After addition of contrast agents, the anterior pituitary gland was found to be highly intense on 78% of T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient-echo (MPRAGE) 3-tesla MR images compared with 73% of standard T1-weighted MR images. The optochiasmatic system displayed increased intensity on pre-contrast T1-weighted MPRAGE 3-tesla compared with standard T1-weighted MR images; it was hyperintense on 76% of 3-tesla compared with 15% of standard MR images, which was helpful for its delineation from suprasellar pituitary and tumor structures. Intraoperative navigation guided by fusion of 3-tesla MR images and computerized tomography (CT) scans was performed in seven patients. Whereas CT scanning was used during the transsphenoidal approach to depict the nasal bone structures, 3-tesla MR imaging was particularly useful for the visualization of parasellar tumor extension during microsurgical and/or endoscopic resection. CONCLUSIONS: Due to its higher resolution, 3-tesla MR imaging was found to be superior to standard MR imaging for the delineation of parasellar anatomy and tumor infiltration of the cavernous sinus, and this modality provided improved imaging for intraoperative navigation.

Adenoma↗

Investigation of apparent diffusion constant as an indicator of early degenerative disease in articular cartilage.

PURPOSE: To investigate the apparent diffusion constant (ADC) as a prospective magnetic resonance imaging (MRI) marker of early degeneration in articular cartilage. MATERIALS AND METHODS: Early degenerative changes were studied using in vitro MRI on cartilage-bone specimens excised from human femoral condyles. The loss of proteoglycans developed in vivo due to a degenerative process was compared with a gadolinium diethylenetriamine pentaacetate anion (Gd-DTPA(2-)) enhanced decrease of T(1) relaxation times, and with an increase of ADCs and T(2) relaxation times. RESULTS: Contrast enhanced T(1) values decreased and the diffusion constants increased in cartilage regions with depleted proteoglycans. The relative changes in diffusion constants were smaller than those of Gd-DTPA(2-) enhanced T(1), and in some proteoglycan-depleted regions no changes in the diffusion constants were detected. T(2) relaxation times showed considerable spatial variability that did not correlate with proteoglycan concentration. CONCLUSION: In contrast to Gd-DTPA(2-) enhanced T(1), which reflects changes in chemical composition, diffusion constants may reflect structural degradation of the cartilage matrix.

Cartilage, Articular↗

Correlative high-resolution MR-anatomic study of sciatic, ulnar, and proper palmar digital nerve.

Aim of this study was o evaluate the effectiveness of high-resolution MR imaging in demonstrating the anatomic structure of peripheral nerves of different diameter and composition. The dissected sciatic, ulnar, and proper palmar digital nerve of fresh cadavers were imaged at pre-selected landmarks on a 3T MR scanner. The nerves were then embedded in formalin, sliced, stained, and microscopically analyzed. The size, shape, and signal intensity of the sheath and axonal structures in the nerves at the landmarks were identified in MR images by comparison with histologic sections. The fascicles were clearly distinguished and counted in all specimens with MR imaging and showed only small differences from the histologic evaluation. High resolution MR imaging has the potential to visualize the fascicular structure in nerves of all sizes, which may be helpful in the preoperative assessment.

Fingers↗