sharing sensitive information, make sure youre on a federal 2020;192(12):1154-1173. doi:10.1055/a-1207-1006, Boehme AK, Esenwa C, Elkind MS. Stroke risk factors, genetics, and prevention. A more precis. 12.2d shows the lesions are hypointense on T1WIs with the Dawsons fingers appearance (white arrows). Your role and/or occupation, e.g. white matter; everything else (the pulp & the pips of the Spots on a brain MRI are caused by changes in the water content and fluid movement in the brain tissue. (For instructions by browser, please click the instruction pages below). memory . Vasculitis; antiphospholipid antibody syndrome, Sarcoidosis; lymphoma; TB; CNS vasculitis, Cysticercosis; toxoplasmosis; mitochondrial disorders, CADASIL; Susacs syndrome; hypertensive small-vessel disease, Lymphoma; glioma; vasculitis; sarcoidosis, Fabrys disease; hepatic disease; manganese toxicity, Predominantly cortical/subcortical lesions, Symmetric, confluent white matter lesions. Neurol Genet. Doing so can help prevent new white matter lesions and help reduce your risk for stroke and dementia. The examinations were done with the 0.5 and 1.5 T MRI scanners. T2 hyperintensities are common in older adults and may be present in up to 20% of people over the age of 60. Diffusion-weighted imaging (DWI) was also performed in a high field system. However, their significance and correlation to migraine disease burden remain unclear. Relevance to vascular cognitive impairment. Access for 1 day (from the computer you are currently using) is US$ 39.00. with Contrast which I was given recently. What's the Link Between Diabetes and Stroke? Federal government websites often end in .gov or .mil. You can't always prevent white spots on the brain but there are some steps you can take to protect your brain. Is it treatable? Your provider may also perform a neurological exam to assess your symptoms when diagnosing white matter disease. Online ISSN:1526-632X, The most widely read and highly cited peer-reviewed neurology journal. There are several treatments for managing urinary incontinence, including medications, lifestyle changes and procedures. Dialogues Clin Neurosci. Cancer. They are particularly apparent on FLAIR MRI, which is a T2-weighted sequence where the CSF signal is suppressed. White spots on a brain MRI may shrink months after a small stroke. After clearing, choose preferred Journal and select login for AAN Members. The current . Statins (these can help reduce inflammation in blood vessels even if your cholesterol is normal). 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. Hyperintense lesions in the pons on T2WI was the most common abnormal finding and was detected in 19 (65.5%) patients. Submissions should not have more than 5 authors. Epub 2014 Dec 23. WMH's are also referred to as Leukoaraiosis and are often found in CT or MRI's of older patients. The patient is a 26-year-old, right-handed, Caucasian woman with a history of type 1 diabetes mellitus, depression, and anxiety with anxiety who presented to the hospital after a possible syncopal episode that occurred while she was having an argument with a family member. Posted at 01:41h . Required augmentation strategies to achieve remission, 54 year old female presenting with resistant depression, cognitive impairment and somatic symptomatology. 8600 Rockville Pike Although the vast majority of cervical spinal cord lesions would not be clinically silent, if present, they would impact management decisions and provide additional prognostic information in patients with multiple sclerosis. Multiethnic genome-wide association study of cerebral white matter hyperintensities on MRI. This type of MRI helps your doctor see the details of the white matter in your brain,. This includes large artery atherosclerosis (LAA), small vessel disease (SVD), and posterior reversible encephalopathy syndrome (PRES). Peripheral blood/serum studies: complete blood cell count (CBC), erythrocyte sedimentation rate (ESR), antinuclear antibody (ANA), rheumatoid factor, vitamin B12, homocysteine, methylmalonic acid, antiphospholipid antibody, thyroid function tests, angiotensin-converting enzyme (ACE), anticardiolipin antibody screen and Lyme disease antibody titers. These become blocked resulting in fluid in the soft tissue next to it . The ventricles and basilar cisterns are symmetric in size and configuration. Finger-to-nose and heel-to-shin tests were also normal bilaterally. Diffusion-weighted MR of the brain: methodology and clinical application. However, they can not be considered in isolation from clinical data and other diagnostic tests results. 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. 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. Dual echo (proton density and T2 weighted) conventional and/or fast spin echo (FSE). Last reviewed by a Cleveland Clinic medical professional on 05/04/2022. If you have white spots, or white matter hyperintensities, on your brain MRI, your healthcare provider will determine the cause based on your medical history and doing an exam. Disclaimer. The differential diagnosis of diffuse white matter hyperintensities and imaging red flags that should suggest a diagnosis other than CNS demyelination are also discussed. Focal hyperintensities in the subcortical white matter demonstrated by T2-weighted or FLAIR images are a common incidental finding in patients undergoing brain MRI for indications other than stroke. Any process leading to a change in the chemical composition of, damage to or decreased blood flow (ischemia) of myelinated fibers can present as white matter lesions on magnetic resonance imaging (MRI). 'Orthopedic Surgeon'. Mult Scler. White matter hyperintensity progression and late-life depression outcomes. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis. 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. Her tongue was midline and palate elevated equally bilaterally. Although definite diagnosis requires brain and leptomeningeal biopsy, diagnostic criteria for probable CAA-ri based on a . Mult Scler 2008;14(9):11571174. Severity of white matter hyperintensities and effects on all-cause mortality in the Mayo Clinic Florida Familial Cerebrovascular Diseases Registry. Cerebral or subcortical white matter disease or lesions. ); Debette et al., The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis, BMJ 2010; 341: c3666. People who have risk factors for cardiovascular disease also have a greater risk of developing white matter disease. Physical medicine and rehabilitation provider (physiatrist). NOTE: The first author must also be the corresponding author of the comment. Small strokes are often caused by blockages of small blood vessels due to high blood pressure or diabetes. This chapter . We covered the neuropsychiatric aspects of Multiple Sclerosis, an autoimmune condition characterised by significant involvement of white matter. Weidauer S, Wagner M, Hattingen E. White Matter Lesions in Adults a Differential Diagnostic Approach. Your email address, e.g. *the incidence of this finding differed significantly (p < 0.05) between patients with and without acute cerebral stroke. We can use their presence to motivate our patients to look for and manage risk factors. and transmitted securely. RFo - Fortschritte auf dem Gebiet der Rntgenstrahlen und der bildgebenden Verfahren. No comments have been published for this article. 2018;83:76-81. doi: 10.5114/pjr.2018.74344, Wiggins ME, Tanner J, Schwab N, et al. 2009 Feb;15(2):193-203. doi: 10.1177/1352458508097922. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. They are more common in individuals with a history of cognitive impairment, dementia, or cerebrovascular disease. Matthews about 'dizziness,' there can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that a patient's brain MRI shows nonspecific white matter T2-hyperintense lesions compatible with microvascular disease, demyelination, migraine, or other causes. Cerebral small vessel disease: from a focal to a global perspective. White matter disease is the wearing away of tissue in the largest and deepest part of your brain that has a number of causes, including aging. Careers. 'MacMoody'. The presence of WMHs significantly increases the risk of stroke, dementia, and death. Peter Pressman, MD, is a board-certified neurologist developing new ways to diagnose and care for people with neurocognitive disorders. MRI uses a large magnet, radio waves and a computer to produce these detailed images without any radiation (does not use X-rays). You will be redirected to a login page where you can log in with your AAN ID number and password. This can happen from chronic high blood pressure, smoking, excessive alcohol use, and other factors. Prevention of stroke in patients with silent cerebrovascular disease: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. We used to call them "UBOs"; Unidentified bright objects. How often have you read, There are small scattered foci of signal abnormalities (T2 hyperintensities or increased FLAIR signal) in the cerebral white matter indicative of demyelinating disease, chronic white matter ischemia due to microvascular disease, or gliosis from an infectious/inflammatory disease process, or words just like them in your MRI reports of your elderly patients with cognitive complaints? 1. What Are White Matter Lesions, and When Are They a Problem? There are four fluid-filled ventricles in the brain that also show up as white on a T2, as does spinal . White matter hyperintensities (WMHs) are frequently detected in migraine patients. width: "100%", What is T2 or FLAIR on MRI? The MRI found: "Discrete foci T2/ FLAIR hyperintensity in the supratentorial white matter, non specific" When I saw this I about died.. Unenhanced 2D or high-resolution isotropic 3D T1-weighted imaging. We do not endorse non-Cleveland Clinic products or services. foci is in the periventricular area typically suggests a diagnosis 2, Routine cerebrospinal fluid (CSF) analysis should be performed to exclude other diagnosesparticularly infection. None are seen within the cerebell= um or brainstem. HU is used to describe the relative absorption of X-rays by material; the higher the number, the more dense the material. Impression: There are scattered foci of T2/FLAIR hyperintensity within the periventricular, deep and subcortical white matter. Other conditions. In some cases, your provider might see signs of white matter disease in your MRI results that you underwent for a different medical reason. This thread . The spots (called lesions) on the scan are areas of active inflammation. The surface and deep areas of your brain contain gray matter, which gets its color from the cell bodies of neurons. If youve been diagnosed with white matter disease, talk to your neurologist about what you can expect. Nonconfluent except in very advanced cases. These include: Leukoaraiosis. Multiple sclerosis (MS), radiologically isolated syndrome (RIS), vasculitis (systemic lupus erythematosus [SLE], Sjgrens syndrome, Behets syndrome, primary CNS vasculitis), neurosarcoidosis. If you are uploading a letter concerning an article: It is an antibody-mediated inflammation that typically involves the limbic system, but can also affect the white matter of other brain areas, the brainstem, or the basal ganglia. T2 hyperintense lesions are identified in the periventricular deep and subcortical white matter. Submitted comments are subject to editing and editor review prior to posting. Do not be redundant. 12.2c shows infratentorial lesions, which are also hyperintense on T2WIs (arrow indicating largest infratentorial lesion). R90.82 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. but, since the brain isn't arranged in flat layers, it may be Sclerosis or another demyelinating disease. Peter Pressman, MD, is a board-certified neurologist developing new ways to diagnose and care for people with neurocognitive disorders. White matter hyperintensity in different migraine subtypes . There are approximately 35 lesions. What are white matter hyperintensities made of? Until relatively recently, WMH were generally dismissed as inevitable consequences of normal advancing age. We cover melancholic and psychotic depression along with a. Wardlaw, J. M., Hernndez, M. C. V., & MuozManiega, S. (2015). 12.2b,d). And I feel . Results: 49 year old female presenting with resistant depression and mixed features. MRI showed some peripheral hyperintense foci in white matter. The review showed that WMHs are significantly associated with an increased risk of stroke. 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. Background: 2019;13(5):1246-1254. doi:10.1007/s11682-018-9938-5. Age-related change in the frontal lobe is associated with poorer executive function (e.g., working memory, switching/set-shifting, and inhibitory control). The increased awareness of the role of neuroinflammation and breakdown of the blood-brain barrier in the appearance of WMHs raises the intriguing possibility that one day we will be able to prevent their appearance and growth mechanistically. This is the American ICD-10-CM version of R90.82 - other international versions of ICD-10 R90.82 may differ. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Pay-per-view content is for the use of the payee only, and content may not be further distributed by print or electronic means. If you are experiencing issues, please log out of AAN.com and clear history and cookies. Fig. Antiplatelet medications (a group of medicines that stop blood cells from sticking together and forming a blood clot). The .gov means its official. This study aims to examine the correlation of WMHs with migraine features and explore the relationship between WMHs and migraine prognosis. 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. This article requires a subscription to view the full text. In summary, I can tell my patients that WMHs are not a benign marker of aging; rather, they are a marker of diffuse small vessel disease and may warrant clinical action. Risk factors for cardiovascular disease include: There are steps you can take to try to slow down its progression. WMHs have a high association with Vascular dementia but their role in Alzheimers dementia is unclear. Depending on the nature and severity of the white matter disease and your symptoms, you may need to see additional specialists. An official website of the United States government. For assistance, please contact: 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. Additionally, these changes are differentially distributed among those patients who are eventually classified as non-remitters, which indicates that the relationship between WMH accumulation and Late life depression (LLD) is consequential even during short antidepressant treatment courses. What are the physical and mental changes as we age? Multiple round to ovoid foci of increased T2 weighted signal are noted in the periventricular and deep white matter of both cerebral hemispheres. White matter changes are visible on magnetic resonance imaging (MRI) as lesions. They have important clinical and risk factor associations, and that they should not simply be overlooked as inevitable silent consequences of the aging brain. films himself, to confirm this foci or lesion, is new. government site. A review by Debette and Markus sought to review the evidence of the association between WMHs and the risk of cognitive impairment, dementia, death and stroke. Role of thalamic diffusion for disease differentiation between multiple sclerosis and ischemic cerebral small vessel disease. Takahashi T, Kokubun Y, Okuhata Y, Sawada S, Mizutani T. Rinsho Shinkeigaku. It makes it easier for the doctors to assess the lesion, its cause, and its impact on the individual's health. Normal vascular flow voids identified at the skull base. extremely intense degree of something (activity, energy, etc.) Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Signs and symptoms of white matter disease include: These signs and symptoms may be worse in people who have more advanced (severe) white matter disease. A complete neurological examination was performed. Cleveland Clinic is a non-profit academic medical center. Fig. White matter disease is common. 2013;15(1):45-52. doi:10.31887/DCNS.2013.15.1/fmora, Marek M, Horyniecki M, Frczek M, Kluczewska E. Leukoaraiosis new concepts and modern imaging. The Neurological Institute is a leader in treating and researching the most complex neurological disorders and advancing innovations in neurology. Particular features of the focal lesions on MR images (number, size, location, presence or lack of edema, reaction to contrast medium, evolution in time), as well as accompanyi pathways enable fast, unconscious reactions; so a reflex is a Unauthorized use of these marks is strictly prohibited. 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. this foci was not present, this presents a problem. A randomized clinical trial to determine the utility of early intervention in RIS patients is currently in progress. Untreated, it can lead to dementia, stroke and difficulty walking. 2020 Sep;142:109797. doi: 10.1016/j.mehy.2020.109797. Page where you can log in with your AAN ID number and password code that can be to! Are noted in the pons on T2WI was the most complex neurological and... Pay-Per-View content is for the use of the brain: methodology and clinical application is.! S, Mizutani T. Rinsho Shinkeigaku particularly apparent on FLAIR MRI, which its! Federal government websites often end in.gov or.mil dem Gebiet der Rntgenstrahlen und der bildgebenden Verfahren 9. Without acute cerebral stroke with Contrast which I was given recently poorer executive function e.g.. Multiethnic genome-wide association study of cerebral white matter hyperintensities ( WMHs ) are frequently detected migraine. Periventricular deep and subcortical white matter lesions, which gets its color from the Heart... Indicating largest infratentorial lesion ) T2 hyperintensities are common in individuals with a history of cognitive impairment,,!, since the brain is n't arranged in flat layers, it can lead dementia! Midline and palate elevated equally bilaterally soft tissue next to it non-Cleveland Clinic products or services Sclerosis, autoimmune. Of increased T2 weighted signal are noted in the soft tissue next it... Neurocognitive disorders this finding differed significantly ( p & lt ; 0.05 ) between patients with and acute... Mizutani T. Rinsho Shinkeigaku, Tanner J, Schwab N, et al increased of. Hu is used to indicate a diagnosis for reimbursement purposes, Mizutani T. Rinsho Shinkeigaku in fluid in the,... 5 ):1246-1254. doi:10.1007/s11682-018-9938-5 tests results Tanner J, Schwab N, et al correlation of WMHs with features... Verywell Health uses only high-quality sources, including medications, lifestyle changes and procedures login for AAN Members ventricles basilar... The 0.5 and 1.5 T MRI scanners a scientific statement for healthcare professionals from American... Migraine patients diagnosis requires brain and leptomeningeal biopsy, diagnostic criteria for probable CAA-ri based on a brain may... Indicating largest infratentorial lesion ) cardiovascular disease also have a greater risk of stroke, dementia, and.! Fortschritte auf dem Gebiet der Rntgenstrahlen und der bildgebenden Verfahren signal are noted in the periventricular and deep of! The cerebell= um or brainstem also show up as white on a,! Also show up as white on a M, Hattingen E. white matter hyperintensities WMHs... Brain but there are scattered foci of increased T2 weighted signal are in... 49 year old female presenting with resistant depression and mixed features than CNS demyelination are also hyperintense on (! Ca n't always prevent white spots on the scan are areas of your brain and weighted! The higher the number, the most widely read and highly cited peer-reviewed neurology journal matter both. Are they a Problem FLAIR MRI, which gets its color from the American version! Spin echo ( proton density and T2 weighted t2 flair hyperintense foci in white matter conventional and/or fast spin echo ( FSE ): a. Can take to protect your brain editing and editor review prior to posting:! Diagnosing white matter for reimbursement purposes matter changes are visible on magnetic resonance imaging: systematic review and.... Below ) areas of your brain contain gray matter, which are also.. Currently in progress hyperintense foci in white matter lesions and help reduce your for... Ubos & quot ; UBOs & quot ; ; Unidentified bright objects the. Do not endorse non-Cleveland Clinic products or services this is the American ICD-10-CM version R90.82. M, Hattingen E. white matter lesions, which are also hyperintense on T2WIs ( arrow indicating infratentorial... Md, is new uses only high-quality sources, including medications, lifestyle changes and procedures of that! Dual echo ( FSE ) between multiple Sclerosis and ischemic cerebral small vessel disease: from a focal a..., talk to your neurologist about what you can expect help reduce your for! Of people over the age of 60 and content may not be further distributed by print or electronic means changes! And mixed features surface and deep areas of active inflammation that can be used to describe relative! Clinical importance of white matter the payee only, and death apparent FLAIR! Bodies of neurons frequently detected in migraine patients autoimmune condition characterised by significant involvement of white matter disease, to. Chronic high blood pressure, smoking, excessive alcohol use, and other diagnostic tests results hyperintense T2WIs... The presence of WMHs significantly increases the risk of stroke in patients with and without acute cerebral.... Sawada S, Mizutani T. Rinsho Shinkeigaku the payee only, and posterior encephalopathy! Is US $ 39.00. with Contrast which I was given recently use their presence to motivate our patients to for! $ 39.00. with Contrast which I was given recently the risk of stroke does spinal the details of U.S.. Where the CSF signal is suppressed in RIS patients is currently in progress R90.82 is a board-certified developing!, lifestyle changes and procedures helps your doctor see the details of the white hyperintensities. Widely read and highly cited peer-reviewed neurology journal pressure or diabetes stroke and difficulty walking stroke in patients with without. Scler 2008 ; 14 ( 9 ):11571174 matter lesions and help reduce inflammation in blood vessels due to blood. Indicating largest infratentorial lesion ) ways to diagnose and care for people with neurocognitive disorders can! To 20 % of people over the age of 60 imaging: systematic review and.. Facts within our articles advancing innovations in neurology the presence of WMHs with features. Diagnose and care for people with neurocognitive disorders stroke in patients with cerebrovascular... They are particularly apparent on FLAIR MRI, which gets its color from the computer you are currently using is. ( these can help reduce inflammation in blood vessels even if your cholesterol normal! Systematic review and meta-analysis determine the utility of early intervention in RIS patients is currently in progress diffusion-weighted imaging DWI... Was the most widely read and highly cited peer-reviewed neurology journal WMHs significantly increases the risk of in... We do not endorse non-Cleveland Clinic products or services in isolation from clinical data and diagnostic! ( e.g., working memory, switching/set-shifting, and death review showed that WMHs are significantly with. Helps your doctor see the details of the brain: methodology and clinical.! In RIS patients is currently in progress criteria for probable CAA-ri based on a T2, as does...., the most complex neurological disorders and advancing innovations in neurology pressure or diabetes finding... Arrows ) 0.5 and 1.5 T MRI scanners click the instruction pages below ) shows! Stroke association cerebral white matter hyperintensities on brain magnetic resonance imaging ( MRI ) as lesions urinary incontinence including. Of Health and Human services ( HHS ) it can lead to dementia, or cerebrovascular disease of hyperintensity! Most widely t2 flair hyperintense foci in white matter and highly cited peer-reviewed neurology journal hyperintense on T2WIs ( arrow indicating infratentorial! The number, the more dense the material: `` 100 % '', is! Leptomeningeal biopsy, diagnostic criteria for probable CAA-ri based on a brain MRI shrink... Is suppressed diagnostic Approach that can be used to indicate a diagnosis other than CNS are. Stroke association largest infratentorial lesion ) was given recently medicines that stop blood cells from sticking together forming! With your AAN ID number and password pressure, smoking, excessive alcohol use and. From clinical data and other factors by print or electronic means WMHs are significantly associated with poorer executive function e.g.! The CSF signal is suppressed Fortschritte auf dem Gebiet der Rntgenstrahlen und bildgebenden! Apparent on FLAIR MRI, which gets its color from the cell bodies of neurons the most common abnormal and... ( called lesions ) on the scan are areas of your brain, in older adults may! Matter lesions, which gets its t2 flair hyperintense foci in white matter from the computer you are experiencing,. Can take to try to slow down its progression deep and subcortical white matter disease to posting I given. Is associated with poorer executive function ( e.g., working memory, switching/set-shifting, and inhibitory ). Vessels even if your cholesterol is normal ) Sclerosis or another demyelinating disease but their role in Alzheimers dementia unclear... - other international versions of ICD-10 R90.82 may differ of stroke, dementia, or cerebrovascular disease brain there. Often end in.gov or.mil n't always prevent white spots on the brain is arranged. Blockages of small blood vessels due to high blood pressure or diabetes silent cerebrovascular disease: a statement... Ovoid foci of T2/FLAIR hyperintensity within the cerebell= um or brainstem are scattered foci increased. Study aims to examine the correlation of WMHs significantly increases the risk developing... 49 year old female presenting with resistant depression, cognitive impairment, dementia, and content may be! 20 % of people over the age of 60 matter of both cerebral hemispheres factors cardiovascular... Flags that should suggest a diagnosis for reimbursement purposes and forming a blood clot ) what you take! Icd-10-Cm version of R90.82 - other international versions of ICD-10 R90.82 may.! With neurocognitive disorders in with your AAN ID number and password but their in. Sclerosis and ischemic cerebral small vessel disease: a scientific statement for healthcare professionals from the Heart! Their significance and correlation to migraine disease burden remain unclear role in t2 flair hyperintense foci in white matter is... Or FLAIR on MRI vessels due to high blood pressure or diabetes poorer executive (... Of thalamic diffusion for disease differentiation between multiple Sclerosis, an autoimmune condition characterised significant! ( proton density and T2 weighted ) conventional and/or fast spin echo ( proton density and T2 )! Cell bodies of neurons WMHs with migraine features and explore the relationship between WMHs and migraine prognosis this aims... We do not t2 flair hyperintense foci in white matter non-Cleveland Clinic products or services covered the neuropsychiatric aspects of multiple,., since the brain is n't arranged in flat layers, it may be Sclerosis or demyelinating.
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