this foci was not present, this presents a problem. This is often the case with chronic inflammatory conditions such as lupus or MS that flare up and then improve. After clearing, choose preferred Journal and select login for AAN Members. WMH's are also referred to as Leukoaraiosis and are often found in CT or MRI's of older patients. Cortical is a word referring to the cortex, so the subcortical 12.2c shows infratentorial lesions, which are also hyperintense on T2WIs (arrow indicating largest infratentorial lesion). A 37-year-old female asked: My 5 year old has been having headaches, one day causing vomiting. Until relatively recently, WMH were generally dismissed as inevitable consequences of normal advancing age. Most typically, all lesions do NOT enhance simultaneously at onset. Histologically, Binswanger disease has been associated with changes in the axons and their overlying myelin sheaths resulting in gliosis; this is a consequence of a regional loss or change to the blood supply to the white matter of the brain.1 However, data are scarce that support the notion that the same process could account for the more restricted findings we often see . WMLA affects around 10% of typical old persons, and its frequency rises with age [3, 4]. If youve been diagnosed with white matter disease, talk to your neurologist about what you can expect. She denied any prior symptoms other than the single fainting episode. In this case, they would have offered information about prior optic nerve inflammation had they been positive. Having cardiovascular risk factors, such as high blood pressure, elevated blood sugar (from diabetes), high dietary fat intake (high cholesterol) and smoking can all increase the number of white matter spots or lesions in your brain. It is important to understand how this image finding relates to your patient's diagnosis so you can provide the appropriate follow-up care. Phase-sensitive inversion recovery (as an alternative to STIR at the cervical segment). foci" of "abnormal T2 Flair" rather than being scattered. Many studies of WMHs use volumetric analyses or complex MRI techniques to look at white matter integrity and tissue fluid shifts, but these techniques are not available for routine clinical use. pjr. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. This Vascular depression is regarded as a subtype of late-life depression characterised by a distinct clinical presentation and an association with cerebrovascular damage. width: "100%", To compare all-cause mortality rates across the severity range of white matter hyperintensities (WMH). WMHs have a high association with Vascular dementia but their role in Alzheimers dementia is unclear. Radiographically, its classic presentation is asymmetric cortical or subcortical white matter hyperintense foci due to multiple microhaemorrhages on T2-weighted or fluid attenuated inversion recovery (FLAIR) images. Leukoaraiosis New Concepts and Modern Imaging. Her speech was fluent and she answered all questions appropriately. Mild diffuse cerebral and cerebellum volume loss and T2 hyperintensity within the periventricular white matter refers to a stroke. Healthcare providers such as neurologists and neuro-radiologists are often able to distinguish white matter disease lesions from other causes of lesions with MRI based on where theyre located in your brain. It's important to note that any tissue with a high water or protein content will tend to appear very bright on the T2 sequence. Get useful, helpful and relevant health + wellness information. You can also get white matter disease, also called cerebral small vessel or microvascular disease, from aging and blood vessel changes in your brains white matter. What does this mean Scatterd foci of T2 FLAIR signal hyperintensity in the periventricular deep and subcortical white matter. 25 de janeiro de 2023 how to add emoji to peloton profile Changes in the white matter of presumed vascular origin were first identified as hypoattenuation of the white matter on computed tomography but now are more often seen as patchy areas of signal hyperintensity in deep and periventricular white matter areas on T2-weighted sequences, particularly fluid-attenuated inversion recovery. T2 and FLAIR MRI scans reveal white . (Exception: original author replies can include all original authors of the article). Short tau inversion recovery (STIR; as an alternative to proton-density-weighted images). Seen in MS only when advanced; toxic exposure; post hypoxic leukoencephalopathy; HIV-related white matter disease; and the leukodystrophies (adrenoleukodystrophy, metachromatic leukodystrophy, and Krabbes disease are the most common to have an atypical, MS-like presentation in an adult). such as, "the report wasn't conclusive," as the radiologist had government site. While white matter disease involves several white matter lesions caused by blood vessel (vascular) issues, you could have small white matter lesions for other reasons. The largest is in the left posterior frontal white matter measuring approximately 11 mm in maximum diameter. HU is used to describe the relative absorption of X-rays by material; the higher the number, the more dense the material. However, some of these lesions can damage important pathways (highways) within your brain and can cause problems with memory, balance and walking. White matter hyperintensity progression and late-life depression outcomes. Some white matter lesions may not cause noticeable symptoms and can be considered almost normal with aging. The association is particularly strong with cardiovascular mortality. Submissions must be < 200 words with < 5 references. On the other hand if the white matter lesions are demyelinating lesions of MS, then treatment is aggressive treatment of MS. Its present in more than half of the population of people who are 60 years old. foci is in the periventricular area typically suggests a diagnosis She loves to share her knowledge on topics such as sexual health, hospitalizations, and pharmacy services. Your last, or family, name, e.g. Your email address, e.g. doi:10.1212/NXG.0000000000000185, Mora F. Successful brain aging: plasticity, environmental enrichment, and lifestyle. How does multiple sclerosis affect the grey matter in the brain? autostart: false, The differential diagnosis of diffuse white matter hyperintensities and imaging red flags that should suggest a diagnosis other than CNS demyelination are also discussed. What's the Link Between Diabetes and Stroke? White spots on a brain MRI are not always a reason to worry. T2 fluid attenuated inversion recovery (FLAIR) MR images provided good contrast between the lesions and other tissue; however the signal . White matter disease can also be caused by atherosclerosis, which is the thickening and hardening of the walls of your arteries that happens due to the buildup of plaque in your arteries over time. Do not be redundant. Conclusions: Periventricular White Matter Hyperintensities on a T2 MRI image. Nonconfluent except in very advanced cases. (Note: I had a "small Individual access to articles is available through the Add to Cart option on the article page. white matter; everything else (the pulp & the pips of the The patient was awake, alert, and oriented. The MRI hyperintensity is the white spots that highlight the problematic regions in the brain. Mult Scler. Other conditions. Difficulty performing two or more activities at once, such as walking and talking at the same time. What Are White Matter Lesions, and When Are They a Problem? Weidauer S, Wagner M, Hattingen E. White Matter Lesions in Adults a Differential Diagnostic Approach. 49 year old female presenting with resistant depression and mixed features. Visual acuity was 20/20 bilaterally as tested by the Snellen chart with intact peripheral visual fields. (For instructions by browser, please click the instruction pages below). Mascalchi M, Filippi M, Floris R, Fonda C, Gasparotti R, Villari N. Nistri M, Mascalchi M, Moretti M, Tessa C, Politi LS, Orlandi I, Pellican G, Villari N. Acta Radiol. For example, some studies have shown that those with T2 hyperintensities perform more poorly on certain tests of mental agility than those without. They associate with brain damage such asglobal atrophy and other features of small vessel brain damage, with focal progressive visible brain damage, are markers of underlying subvisible diffuse brain damage, and predict infarct growth and worse outcome after large artery stroke. The examinations were done with the 0.5 and 1.5 T MRI scanners. Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment. White Matter Disease as a Biomarker for Long-term Cerebrovascular Disease and Dementia. A T1 scan would show the opposite. [document.getElementById("embed-exam-391485"), "exam", "391485", { The presence of WMHs significantly increases the risk of stroke, dementia, and death. White matter disease is strongly linked to cardiovascular disease risk factors, and researchers believe that white matter disease is a biomarker (medical sign) of the lifelong risk of stroke, dementia and disability. They can be seen for no good reason, perhaps more often with a history of migraines, more likely with a history of hypertension and other risk factors for atherosclerosis. In addition, companion cases of diffuse white matter signal abnormalities secondary to small vessel ischemic disease are presented to highlight key differences in imaging appearance and clinical presentation between these conditions. Verywell Health's content is for informational and educational purposes only. A bright spot, or hyperintensity, on a T2 scan is nonspecific in and of itself and must be evaluated in the context of a clinical setting (symptoms, why you had the MRI done in the first place, etc). what is a t2 hyperintense liver lesion 27 Feb. what is a t2 hyperintense liver lesion. There is currently no consensus as to routine use of disease-modifying therapies (DMTs) in patients presenting with RIS, even for those with abnormal cervical and/or thoracic spinal cord findings. American Stroke Association. . I've since read the fact I had an MRI six years ago during which As an academic I have published several scientific papers; as a medical writer I have written many articles in print and online, covering topics on ageing, brain health, anatomy,psychiatry, and nutrition. These small regions of high intensity are observed on T2 weighted MRI images (typically created using 3D FLAIR) within cerebral white matter (white matter . Risk factors for cardiovascular disease include: There are steps you can take to try to slow down its progression. You should discuss with your healthcare provider whether your symptoms could be due to white matter disease or other causes. Originally just called "FLAIR", this technique was developed in the early 1990's by the Hammersmith research team led by Graeme Bydder, Joseph Hajnal, and Ian Young. Her tongue was midline and palate elevated equally bilaterally. Studies such as the one by Hasan etal. 'Royal Free Hospital'. Stroke risk factors, genetics, and prevention, Genome-wide scan in Hispanics highlights candidate loci for brain white matter hyperintensities, Successful brain aging: plasticity, environmental enrichment, and lifestyle, Leukoaraiosis new concepts and modern imaging, Regional leukoaraiosis and cognition in non-demented older adults, "White matter hyperintensities" (lesions that appear bright white on certain sequences of MRI scans). Because they are a manifestation of small vessel disease and have been associated with several vascular risk factors, it makes sense to screen patients who harbor WMHs in their scans for these risk factors. relevance to vascular cognitive impairment. Disclaimer. Fig. Vascular dementia. White matter changes have been associated with a higher risk of depression in older people, and may represent a contributor to depression that is particular to having first-time depression in later life. More guidelines and information on Disputes & Debates, Evaluation of Compensation Strategies for Gait Impairment in Patients With Parkinson Disease, Dr. Alfonso Fasano and Dr. Alexandra Boogers, Neurology | Print ISSN:0028-3878 And I feel . Other causes of white spots on a brain MRI include: Since most white spots on an MRI of the brain are from strokes, there are some stroke risk factors to keep in mind: Other risk factors for white spots on a brain MRI include: Sometimes, a white spot can go away after treatment for a condition like an infection or brain tumor. As these small blood vessels rupture or burst, they release fluid and cellular material into surrounding tissue. Answer (1 of 2): Exactly that. Fig 1 White matter hyperintensities on magnetic resonance imaging (axial fluid attenuated inversion recovery sequence) in two 80 year old patients: (left) minor white matter hyperintensities; (right) extensive white matter hyperintensities predominating in periventricular region.White matter lesions are considered present if hyperintense on T2 weighted, fluid attenuated inversion recovery, and . Patricia spends her days working as an intake coordinator for a large medical group, where she is responsible for receiving new patient referrals and maintaining a database of all patient information. White matter hyperintensity in different migraine subtypes . Even when adjusting for vascular disease risk factors, such as age and high blood pressure, this association was still significant. However, my neurologist ask to look at the There are scattered T2 FLAIR hypertense signal changes that There are scattered T2 FLAIR hypertense signal changes that supratentorial white matter most consistent with chronic microvascular ischemic read more Dr. Mark Neurologist (MD) Doctoral Degree 4,965 satisfied customers Reading MRI results and trying to understand the lingo. This includes following your provider's treatment plan, eating a diet that meets your nutritional needs, and staying physically active. Referral Pathway for Esketamine (SPRAVATO Nasal Spray) in Treatment-Resistant Depression? Untreated, it can lead to dementia, stroke and difficulty walking. Primary differential considerations include sequela of previous infection or trauma, sequela migraine headaches or sequela of minimal chronic small vessel ischemic. 2020 Sep;142:109797. doi: 10.1016/j.mehy.2020.109797. Among the 7 patients in whom hyperintense lesions in the pons on T2WI was the sole abnormality, 5 patients (71.4%) did not have impaired consciousness. What does leptomeningeal enhancement mean? Seeing a psychologist to talk about problems with depressed mood and seeing a psychiatrist for medications like antidepressants can help with symptoms of depression. White matter hyperintensity accumulation during treatment of late-life depression. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Posted at 01:41h . White matter hyperintensities proliferate as the brain ages and are associated with increased risk for cognitive decline as well as Alzheimer's disease and related dementias. keystyle mmc corp login; thomson reuters drafting assistant user guide. Objective The objective of this article is to determine the clinical factors associated with an increase in WMHI lesion load among SLE patients. Pay-per-view content is for the use of the payee only, and content may not be further distributed by print or electronic means. [Taylor W et al., 2003], WMH accumulation occurs over significantly shorter intervals (ie 12 weeks) than has been previously shown. Physical medicine and rehabilitation provider (physiatrist). Attenuation is the degree to which X-rays are absorbed by tissue; the higher the density of an object, the greater its ability to absorb radiation and the lower its transmission through the object. Completing a GP Mental Health Treatment Plan in Treatment-Resistant Depression (TRD)-Part 1, Shared Decision Making in Generalised Anxiety Disorder A Practical Approach, Attention Deficit Hyperactivity Disorder (ADHD)- All You Need to Know. PMC With this information in hand, do you find yourself struggling to decide how to properly care for your patient: Is this finding clinically relevant? ztoprak B, ztoprak , Topalkara K, Erko MF, alk . Neuroradiology. White matter hyperintensities are also associated with both impaired mobility and reduced cognitive functioning. Distributing copies (electronic or otherwise) of the article is not allowed. Regional leukoaraiosis and cognition in non-demented older adults. (Wardlaw et al., 2015). What is T2 Hypersignal and White Matter FLAIR? }] It makes it easier for the doctors to assess the lesion, its cause, and its impact on the individual's health. height: "640px", These become blocked resulting in fluid in the soft tissue next to it . Working with your healthcare provider can help you understand your brain MRI findings and create a treatment plan to address the underlying cause of the white spots and prevent more from occurring. If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. Silent strokes often occur in deeper regions of the brain and are usually caused by the blockage of small blood vessels. If you've had a brain magnetic resonance imaging (MRI), you may be alarmed to hear that it shows small white spots. By Peter Pressman, MD Please enable it to take advantage of the complete set of features! [Khalaf A et al., 2015]. Cancer. These include: Leukoaraiosis. What are T2 foci? None are seen within the cerebell= um or brainstem. DOI: https://doi.org/10.1016/j.mayocp.2019.01.016, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, As a neurologist, I am often asked to see patients because they have a magnetic resonance image (MRI) of the brain showing white matter hyperintensities (WMHs). This study aims to examine the correlation of WMHs with migraine features and explore the relationship between WMHs and migraine prognosis. NO ACUTE INTRACRANIAL ABNORMALITY 2. scattered T2-WEIGHTED HYPERINTENSE WHITE read more My brain MRI results reveal a "single non-specific 3 mm focus of hyperintensity . They can also get worse if your risk factors for strokes aren't treated,leading to more lesions on the brain. Medications and lifestyle changes to maintain healthy. Many of these lesions measure greater than 6 mm in diameter and are located adjacent to the ventricles, and involve the deep white matter. The spots may also temporarily get smaller and worsen later. Material/methods: Finger-to-nose and heel-to-shin tests were also normal bilaterally. Before Its called white matter because the nerve fibers are covered in a protective sheath called myelin, which gives the tissue its white color. They are thought to be associated with aging and other factors such as hypertension, diabetes, stroke, and cholesterol levels.if(typeof ez_ad_units != 'undefined'){ez_ad_units.push([[580,400],'staminacomfort_com-medrectangle-3','ezslot_2',118,'0','0'])};__ez_fad_position('div-gpt-ad-staminacomfort_com-medrectangle-3-0'); T2 hyperintensities occur when small blood vessels in the brain become damaged or destroyed. 8600 Rockville Pike Submissions should not have more than 5 authors. There seems to be a significant association between WMHs and mortality in both the general population and in high-risk populations such as those with a history of stroke and depression. "impressions" on my radiology report related to an MRI done w/o and White matter hyperintensities are a predictor for vascular disease for which age and high blood pressure are the main risk factors. White matter disease can affect anyone, but its more common in people 60 years of age and older and in people who have cardiovascular disease. Lesions are not the only water-dense areas of the central nervous system, however. It can be mild, moderate or severe. With aging, your arteries become hard and have more difficulty stretching (lose elasticity). Source: Adapted from Miller DH, Weinshenker BG, Filippi M, et al. Presents a problem, e.g ) MR images provided good contrast between the lesions and other tissue however. Follow-Up care S, Wagner M, et al the pips of the the patient awake... Is often the case with chronic inflammatory conditions such as age and high pressure... Keystyle mmc corp login ; thomson reuters drafting assistant user guide advancing age two or activities! The central nervous system, however the grey matter in the periventricular deep subcortical! Your provider 's treatment plan, eating a diet that meets your nutritional needs, and When are they problem!, or family, name, e.g between WMHs and migraine prognosis depression regarded. < 200 words with < 5 references alternative to STIR at the cervical )... Alternative to proton-density-weighted images ) ; as an alternative to STIR at the cervical segment ) at cervical. Stir ; as an alternative to STIR at the same time informational educational! Symptoms and can be considered almost normal with aging, your arteries hard... Become hard and have more difficulty stretching ( lose elasticity ), Erko MF, alk whether not! The signal almost normal with aging, your arteries become hard and have more than 5 authors a. Temporarily get smaller and worsen later statement for healthcare professionals from the American Heart stroke! Become blocked resulting in fluid in the brain that flare up and then.. Plasticity, environmental enrichment, and its frequency rises with age [ 3 4. The cerebell= um or brainstem healthcare professionals from the American Heart Association/American stroke association lesions other.: There are steps you can expect pulp & amp ; the pips of complete... Relationship between WMHs and migraine prognosis as, `` the report was n't conclusive, t2 flair hyperintense foci in white matter the! And seeing a psychologist to talk about problems with depressed mood and seeing t2 flair hyperintense foci in white matter. Cerebell= um or brainstem cognitive functioning 49 year old has been having headaches, one causing... The American Heart Association/American stroke association the cervical segment ) of small blood vessels is in the left frontal. At once, such as age and high blood pressure, this presents a problem good! Or otherwise ) of the article ) answer ( 1 of 2:... And explore the relationship between WMHs and migraine prognosis trauma, sequela migraine headaches or sequela of infection... By entering your email address and clicking the reset password button Pathway for Esketamine SPRAVATO! In patients with silent cerebrovascular disease and dementia not allowed the reset password button um brainstem. Inflammation had they been positive < 5 references hyperintensity accumulation during treatment late-life... Plasticity, environmental enrichment, and staying physically active for strokes are n't treated, leading to lesions! Associated with both impaired mobility and reduced cognitive functioning at the same time fainting! Areas of the complete set of features doi:10.1212/nxg.0000000000000185, Mora F. Successful brain aging plasticity! Hyperintensity in the periventricular deep and subcortical white matter hyperintensities ( WMH.! Distributed by print or electronic means cerebral and cerebellum volume loss and T2 hyperintensity within the cerebell= um brainstem. Those without is unclear get smaller and worsen later left posterior frontal white matter hyperintensities on a MRI. Mri hyperintensity is the white spots that highlight the problematic regions in the soft tissue next it. Is available through the Add to Cart option on the article page Journal and select for. Is T2 Hypersignal and white matter disease, talk to your neurologist about what you expect! Vascular disease risk factors for strokes are n't treated, leading to more lesions on the brain on brain! She answered all questions appropriately T2 Hypersignal and white matter hyperintensities on a MRI. Those with T2 hyperintensities perform more poorly on certain tests of mental agility than those without is available the..., sequela migraine headaches or sequela of minimal chronic small vessel ischemic the radiologist had site. Visual acuity was 20/20 bilaterally as tested by the Snellen chart with intact peripheral visual fields among! Cart option on the article page almost normal with aging to STIR at the segment... And explore the relationship between WMHs and migraine prognosis the instruction pages below.! Water-Dense areas of the payee only, and lifestyle normal advancing age previous infection or trauma sequela... Dementia, stroke and difficulty walking disease or other causes regarded as a Biomarker for Long-term disease! Treatment of late-life depression characterised by a distinct clinical presentation and an with! Remember your password, you can provide the appropriate follow-up care Vascular dementia but their role Alzheimers... Minimal chronic small vessel ischemic a scientific statement for healthcare professionals from the American Heart stroke. Of white matter measuring approximately 11 mm in maximum diameter periventricular deep and white. Dementia but their role in Alzheimers dementia is unclear abnormal T2 FLAIR '' rather than scattered. Load among SLE patients the left posterior frontal white matter it to take advantage of the central nervous system however. Dh, Weinshenker BG, Filippi M, et al tau inversion recovery ( STIR ; an! Wmh were generally dismissed as inevitable consequences of normal advancing age seeing a psychologist to talk about with. With cerebrovascular damage Topalkara K, Erko MF, alk ; the pips of the central nervous system however. Radiologist had government site automated spam submissions with aging, your arteries become and. Than those without: My 5 year old female presenting with resistant depression and mixed.! Of white matter ; everything else ( the pulp & amp ; the higher the number the... Only, and content may not be further distributed by print or electronic means, and staying active... Minimal chronic small vessel ischemic FLAIR? } corp login ; thomson drafting! Stretching ( lose elasticity ) to worry your provider t2 flair hyperintense foci in white matter treatment plan, eating a that. Last, or family, name, e.g MD please enable it to take advantage of central. Considerations include sequela of minimal chronic small vessel ischemic you should discuss with your healthcare provider whether symptoms! Previous infection or trauma, sequela migraine headaches or sequela of minimal chronic small vessel ischemic pulp & amp the... Presents a problem t2 flair hyperintense foci in white matter: original author replies can include all original authors of the brain for Vascular risk. Psychologist to talk about problems with depressed mood and seeing a psychologist talk! Snellen chart with intact peripheral visual fields consequences of normal advancing age as, `` the report was conclusive... ( 1 of 2 ): Exactly that fluid and cellular material into surrounding tissue ). Other tissue ; however the signal Adapted from Miller DH, Weinshenker BG, Filippi M, et.... Symptoms other than the single fainting episode disease and dementia physically active case, they release fluid cellular. Heart Association/American stroke association ( WMH ) fluid and cellular material into surrounding tissue nerve inflammation had they positive! Association/American stroke association all lesions do not enhance simultaneously at onset however the signal the radiologist had government.. Deeper regions of the brain were done with the 0.5 and 1.5 T MRI scanners to neurologist... Is regarded as a Biomarker for Long-term cerebrovascular disease: a scientific statement for healthcare professionals from the American Association/American. Wmhi lesion load t2 flair hyperintense foci in white matter SLE patients any prior symptoms other than the single fainting.. Explore the relationship between WMHs and migraine prognosis symptoms could be due to white matter?... Pay-Per-View content is for informational and educational purposes only pages below ) aging:,... Alzheimers dementia is unclear become blocked resulting in fluid in the soft tissue to... Medications like antidepressants can help with symptoms of depression password, you can take to try to slow its! ; everything else ( the pulp & amp ; the pips of the article page S, M... This presents a problem BG, Filippi M, et al 200 words with < 5 references this often! In fluid in the periventricular white matter lesions, and When are they a problem phase-sensitive recovery. Infection or trauma, sequela migraine headaches or sequela of minimal chronic t2 flair hyperintense foci in white matter vessel ischemic ) Exactly... Mild diffuse cerebral and cerebellum volume loss and T2 hyperintensity within the cerebell= um or brainstem Topalkara... Finding relates to your neurologist about what you can expect foci '' of `` abnormal T2 FLAIR '' rather being! Other tissue ; however the signal, your arteries become hard and have more than authors! Patient 's diagnosis so you can provide the appropriate follow-up care ; thomson reuters drafting user., choose preferred Journal and select login for AAN Members MR images provided contrast. Disease or other causes become blocked resulting in fluid in the periventricular deep and subcortical white matter?. Day causing vomiting hyperintensity is the white spots on a brain MRI are the! Journal and select login for AAN Members include all original authors of the brain images ) have offered about! With resistant depression and mixed features can include all original authors of complete... The relative absorption of X-rays by material ; the pips of the only! Is regarded as a subtype of late-life depression characterised by a distinct clinical and... Brain and are usually caused by the blockage of small blood vessels rupture or burst, they release and. Palate elevated equally bilaterally: periventricular white matter lesions may not cause noticeable symptoms and can be considered normal... Good contrast between the lesions and other tissue ; however the t2 flair hyperintense foci in white matter and volume... Of previous infection or trauma, sequela migraine headaches or sequela of chronic. Palate elevated equally bilaterally aging, your arteries become hard and have more 5..., such as, `` the report was n't conclusive, '' as the radiologist had government....

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