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Background: IMA is a novel marker to consider in ischemic conditions. The initial stages of pregnancy represent a physiological ischemic status. IMA levels may be changed when there is suspicion of early pregnancy complications because of increased oxidative stress. Aim: We aimed to determine and compare IMA values in cases of ectopic and healthy pregnancies as well as early pregnancy loss. Methods: This prospective case control study population (n = 91) consisted of early pregnancy loss (n = 28), ectopic pregnancy (n = 28), and an intracavitary early healthy pregnancy (n = 35). The serum IMA levels were compared in these groups. Results: Demographic parameters were similar and there was no significant difference between the three groups in terms of serum IMA concentrations. Conclusion: We suggested that IMA cannot be used clinically for the diagnosis and follow up of early pregnancy complications during the first five to six gestational weeks.
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Aborto Espontáneo , Embarazo Ectópico , Biomarcadores , Estudios de Casos y Controles , Femenino , Humanos , Isquemia , Embarazo , Albúmina Sérica , Albúmina Sérica HumanaRESUMEN
BACKGROUND: Colorectal cancer is one of the most common cancers worldwide. Laparoscopic colorectal surgery (LCRS) is a frequently used modality. A new development in minimally invasive surgery is robot-assisted colorectal surgery (RACRS). METHODS: Prospectively collected data of 378 consecutive patients who underwent RACRS or LCRS for stage I-III colorectal cancer from Dec 2014 to Oct 2017 were analyzed. Primary outcome was oncological outcome (radical margins, number of retrieved lymph nodes, locoregional recurrence). Secondary outcomes were distant metastases, overall and disease-free survival, operation time, conversion, length of hospital stay, and intra- and post-operative complications. RESULTS: 206 RACRS (129 colon and 77 rectal) and 172 LCRS (138 colon and 34 rectal) procedures were included. Baseline characteristics were similar. Overall median follow-up time was 15 months (0.2-36). Oncological outcome was similar. In colon cancer, radical margins were achieved in 99.3% in RACRS group versus 98.6% in LCRS group (p = 0.60), the average number of harvested lymph nodes was 16 ± 6 versus 18 ± 7 (p = 0.16), and locoregional recurrence rate in 24 months was 3.8% vs 3.8% (p = 0.99), respectively. In rectal cancer, radical margins were achieved in 89.6% in RACRS group versus 94.3% in LCRS group (p = 0.42), the average number of harvested lymph nodes was 16 ± 8 versus 15 ± 4 (p = 0.51), and locoregional recurrence rate in 24 months was 9.5 versus 5.6% (p = 0.42), respectively. Incidence of metastasis, survival rates, operation time, length of hospital stay, and number of severe post-operative complications measured by Clavien-Dindo scores did not differ between RACRS and LCRS groups. Conversion and intra-operative complication rates were significantly lower in the RACRS group as compared to the LCRS group (3% vs 9%, p = 0.008 and 2% vs 8%, p = 0.003, respectively). CONCLUSION: RACRS is safe in the treatment of patients with stage I-III colorectal cancer. Oncological outcome did not differ between RACRS and LCRS groups. RACRS had lower conversion and intra-operative complication rates.
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Colectomía/métodos , Neoplasias Colorrectales/cirugía , Complicaciones Intraoperatorias/epidemiología , Complicaciones Posoperatorias/epidemiología , Robótica/métodos , Anciano , Neoplasias Colorrectales/diagnóstico , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Tiempo de Internación , Masculino , Márgenes de Escisión , Recurrencia Local de Neoplasia/epidemiología , Estadificación de Neoplasias , Países Bajos/epidemiología , Tempo Operativo , Estudios Prospectivos , Tasa de Supervivencia/tendenciasRESUMEN
Our objective was to examine the variables affecting diagnostic yield and complications in percutaneous ultrasonography-guided needle biopsies of solid renal masses. Percutaneous ultrasonography-guided needle biopsy of solid renal masses was performed in 172 patients with either large size (18G) cutting needles or small size (20G) aspiration needles. Retrospectively, 120 patients with diagnosis by percutaneous biopsy and follow-up data were included in this series. Age, gender, side, locations in kidneys, necrosis, calcification, maximum size, needle groups due to needle size and type (either 18G cutting needles or 20G aspiration needles), and needle pass were selected as variables. Their role was investigated in diagnostic yield. Two needle groups were divided and compared for diagnostic yield and safety. Also, change in treatment was evaluated. The mean maximum size of the masses was 8.8±4.9 cm. The only predictor affecting accuracy was side of kidney (p=0.002). Among patients, 15 (12.5%) and 105 (87.5%) had benign and malignant solid masses, respectively. Small and large needle groups did not differ in accuracy, 80.3% vs. 87.1% (p=1.000). Technical success was detected as 100%. No major complications neither tumor seeding was seen. Percutaneous ultrasonography-guided needle biopsy of solid renal masses is effective and safe method with large size cutting needles and small aspiration needles. Change in clinical management was significant at 63.3% rate. Diagnostic yield was low in left kidney relating to right kidney, 69.4 vs. 93.1, while upper lobe location did not lead to significant false result. Repeat biopsies can be taken under CT guidance after nondiagnostic diagnosis in solid tumors of left kidney. All the needles including large cutting type were found safe.
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Biopsia con Aguja/métodos , Neoplasias Renales/diagnóstico , Riñón/patología , Adulto , Anciano , Biopsia con Aguja/efectos adversos , Femenino , Humanos , Riñón/diagnóstico por imagen , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , UltrasonografíaRESUMEN
The objective of the study was to determine the predicting factors in malignant diagnosis in ultrasonography guided fine-needle aspiration biopsy of cervical lymph nodes. Design is retrospective follow-up study. Ultrasonography guided fine-needle aspiration biopsies of cervical lymph nodes were performed in 290 patients. The mean age was 45.5 ± 14.4 years (range; 15-85). 207 (71.4%) and 83 (28.6%) were women and men, respectively. Cytopathologist was not present in any biopsy procedure. Factors in predicting malignancy were age, gender, presence of primary malignancy, localization (Level 1-6), hypoechogenicity with loss of echogenic hilum, microcalcification, cystic feature, minimum and maximum sizes, and index value (minimum size/maximum size). Factors were analyzed by univariate and multivariable tests. The mean minimum size and index value of the lymph nodes were 10.4 ± 5.5 mm and 0.58 ± 0.18, respectively. Age, gender, microcalcification, cystic feature, minimum size, and index value were poor predictors in malignancy. Predictors were presence of primary malignancy (p-< 0.001), the level of localization (p=0.001), and hypoechogenicity (p-< 0.001)- in malignancy. Microcalcification and cystic parts were specific US findings of metastasis of thyroid carcinoma; nevertheless cystic parts were seen more specific finding in the other malignancies. Malignant lymph nodes were often found in the presence of primary malignancy, mid neck and lower neck localizations as Level 3-6, and markedly hypoechoic lymph nodes. In 131 patients with a primary thyroid carcinoma, the predictors for malignancy were localization where the most often regions were Level 3, 4, and 6 and hypoechogenicity. Malignancy rate was relatively low in patients with thyroid malignancy than those with non thyroid malignancies in Level 5. Level 6 was the most difficult area for biopsy due to postoperative changes. Microcalcification was specific only in thyroid carcinoma, whereas cystic parts were more specific in the other malignancies
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Biopsia con Aguja Fina/métodos , Ganglios Linfáticos/patología , Metástasis Linfática/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuello , Estudios Retrospectivos , Neoplasias de la Tiroides/patologíaRESUMEN
AIM: Aim of this study was to evaluate the prognostic effect of the magnetic resonance imaging (MRI) infiltration type as diffuse or focal patterns on spine magnetic resonance imaging (MRI), as well as other imaging and clinical features of patients with multiple myeloma. METHODS: A retrospective analysis of 35 patients with multiple myeloma was performed in this study. Patients were mean of 56.5 ± 12.4 year old, male/female ratio=1.3. Patients were at stage 2 and one at stage 3. Skeletal surveys were obtained in all patients, additionally bone scintigraphy (N.=25), CT (N.=22), and spine MRI (N.=16) were conducted. On imaging, lesion number, size and distribution and characteristics were assessed. On MRI, bone marrow involvements were assessed as focal and diffuse patterns (mild, moderate, and severe). All patients were followed-up with MRI for a median of 8.5 months (range, 1-105). Statistical analysis for bone marrow infiltration on MRI was performed using Kaplan-Meier survival test. RESULTS: Patients with diffuse infiltration pattern on MRI survived as median 13.0 months (range, 1-105), whereas cases with only focal pattern survived as median 3.5 months (range, 1-27). There was no difference between these groups (P=0.071). The disease-free survivals were not different, either (P=0.118). Scintigraphy, CT, and MRI detected more lesions in flat bones except for cranium where craniography was successful. CONCLUSION: It was not possible to find any further effect of the diffuse MRI infiltration type beyond focal infiltration on overall and disease-free survivals. Among typical findings of the radiography, spherical, punched-out lesions were seen, but lesion uniformity was not seen.
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Médula Ósea/patología , Imagen por Resonancia Magnética , Mieloma Múltiple/patología , Neoplasias de la Columna Vertebral/patología , Columna Vertebral/patología , Adulto , Anciano , Anciano de 80 o más Años , Médula Ósea/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mieloma Múltiple/diagnóstico por imagen , Mieloma Múltiple/mortalidad , Estadificación de Neoplasias , Pronóstico , Cintigrafía , Estudios Retrospectivos , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Columna Vertebral/diagnóstico por imagenRESUMEN
AIM: The aim of this study was to compare small size aspiration and large size cutting needles on the diagnostic yield in the biopsies of liver and especially to investigate the reliability on percutaneous biopsy of liver hemangiomas. METHODS: Nine hundred fifty patients with percutaneous ultrasonography-guided liver biopsies were evaluated retrospectively. This study enrolled 841 patients biopsied with either large size cutting needle (Tru-cut 14G-18G) or small size aspiration needle (WestCott 20G). Further evaluation was performed in 312 patients with metastasis and 48 patients with hemangiomas. RESULTS: Diagnostic yield was higher in the large size cutting needle group (96.8%, 150/155) than in the small size aspiration needle group (84.1%, 132/157) in liver metastasis (P<0.001). There was no significant difference among diagnostic accuracies of Tru-cut 14G, 16G, and 18 G needles in metastasis (P=0.255). Accuracy rate was 77.9% (208/267) in benign and 89.5% (514/574) in malignant diseases. Sensitivity, specificity, and accuracy were 81.2% (514/633), 100% (208/208), and 85.8% (722/841), respectively. Only two major complications were found (0.16%) with small needles. CONCLUSION: The authors suggest the use of large size cutting needles, because they provide more accurate diagnosis, and should be used in liver metastasis instead of small aspiration needles, if there is no on-site pathologist at aspiration biopsies or a more specific diagnosis is required. Among them, 18G cutting needle should be chosen. All the needles, including the large cutting type, were found safe in the biopsies of liver hemangiomas.
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Biopsia con Aguja Fina/métodos , Hemangioma/patología , Neoplasias Hepáticas/patología , Ultrasonografía Intervencional , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Diagnóstico Diferencial , Femenino , Hemangioma/diagnóstico por imagen , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y Especificidad , Ultrasonografía Intervencional/métodosRESUMEN
AIM: To evaluate the efficacy of single-session percutaneous sclerotherapy with needle aspiration or catheter drainage, under ultrasound (US) or computed tomography (CT) guidance, based on cyst size and depth in 22 symptomatic simple renal cysts. METHODS: Sclerotherapy with 95% alcohol for 20 min was performed in 22 symptomatic simple renal cysts in 15 patients. The method (aspiration or drainage) was chosen according to cyst size and depth: catheter drainage was done for larger (>6 cm) and shallow (<7.5 cm) cysts (N=12) and needle aspiration was done for smaller (<6 cm) or deeper (>7.5 cm) cysts (N=10). The median follow-up period was 6.0 months (range 1-62). RESULTS: Volume reduction of cysts (mean and median, respectively) was 94.1% and 97.0%. Average cyst volume reduction (mean and median, respectively) was 94.7% and 96.0% with US-guided methods and 93.3% and 99.0% with CT-guided methods (P=0.382). Median volume loss was 97.5% with needle aspiration and 96.5% with catheter drainage (P=0.839). No correlation between the groups and volume reduction was found. All procedures were successful. No major complications or recurrences were noted. CONCLUSIONS: Single-session percutaneous alcohol sclerotherapy with needle aspiration or catheter drainage, under US or CT guidance, is an effective and safe method for treating symptomatic simple renal cysts. CT-guided needle aspiration may be more suitable for treating deeper and/or smaller (<6 cm) cysts, while US-guided catheter drainage may be preferable in cases of shallow and/or larger (>6 cm) cysts.
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Etanol/uso terapéutico , Enfermedades Renales Quísticas/terapia , Soluciones Esclerosantes/uso terapéutico , Escleroterapia/métodos , Adulto , Anciano , Etanol/administración & dosificación , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intralesiones , Enfermedades Renales Quísticas/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Radiografía Intervencional/métodos , Estudios Retrospectivos , Soluciones Esclerosantes/administración & dosificación , Succión/métodos , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Intervencional/métodosRESUMEN
Gynecologic malignancies are rarely associated with pregnancy and ovarian tumors diagnosed during cesarean section are very uncommon. A 38-year-old grandmultipara with no prenatal care was hospitalized at an estimated 28 weeks of gestation for high blood pressure and increased proteinuria but no other symptoms of preeclampsia. We present a rare case of advanced ovarian carcinoma diagnosed during cesarean section.
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Adenocarcinoma/diagnóstico , Hallazgos Incidentales , Neoplasias Ováricas/diagnóstico , Preeclampsia , Complicaciones Neoplásicas del Embarazo , Adulto , Cesárea , Femenino , Humanos , EmbarazoRESUMEN
INTRODUCTION: Malabsorptive bariatric procedures, like the biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS), have excellent results in terms of weight loss. However, these malabsorptive techniques are associated with severe malnutrition and vitamin deficiencies. The aim of this study was to evaluate the vitamin and mineral status after BPD and BPD/DS in the long term. METHODS: All patients who underwent BPD or BPD/DS were selected and invited for an additional follow-up (FU) visit, including blood sampling for vitamin and mineral levels. RESULTS: Forty patients completed the blood sampling with a median FU of 42 (range 12-90) months. At that time, all patients used some kind of supplementation. However, 93 % of all patients were diagnosed with a deficiency. There were no significant differences in mean serum level vitamins and minerals between BPD and BPD/DS. Forty-three per cent of the patients were anaemic, and 40 % had an iron deficiency (ID). High deficiency rates for fat-soluble vitamins were present: vitamin A in 28 %, vitamin D in 60 %, vitamin E in 10 % and vitamin K in 60 % of the patients. Hypervitaminosis was found in 43 % of the patients for vitamin B1 and in 50 % for vitamin B6. CONCLUSION: High numbers of vitamin and mineral deficiencies were found after BPD and BPD/DS despite vitamin supplementation. Anaemia, ID and deficiencies for fat-soluble vitamins are frequently diagnosed. Repeated monitoring is necessary to detect deficiencies at an early stage. Taking all of this into consideration, a stringent multivitamin supplementation regimen should be implemented after malabsorptive procedures.
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Anemia/etiología , Avitaminosis/etiología , Desviación Biliopancreática/métodos , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Tiamina/sangre , Vitamina B 6/sangreRESUMEN
Vascular compression syndromes of the peroneal nerve are rare. The case history of a patient with a peroneal nerve compression caused by a true anterior tibial artery aneurysm is reported. The surgical excision of the aneurysm resulted in marked improvement.
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Aneurisma/cirugía , Síndromes de Compresión Nerviosa/cirugía , Nervio Peroneo/cirugía , Arterias Tibiales/cirugía , Aneurisma/patología , Humanos , Masculino , Persona de Mediana Edad , Síndromes de Compresión Nerviosa/patología , Nervio Peroneo/patología , Trombosis/patología , Trombosis/cirugía , Arterias Tibiales/patología , Tomografía Computarizada por Rayos XRESUMEN
A turban is a kind of headcover, worn for religious intentions. In Islamic countries, girls start to wear a turban with the onset of puberty. Turban pins (headscarf needles) are used for attaching the layers of turban to each other in order to keep it in a steady position around the head. Aspiration of these pins is investigated in accordance with age groups, pin characteristics and treatment. From 1987 through 1998, 63 girls were admitted to our department with turban pin aspiration. All patients were healthy prior to aspiration. The median age was 14 years. Foreign bodies were removed, either by rigid bronchoscopy (n = 57), flexible bronchoscopy (n = 2), laryngoscopy (n = 3) or thoracotomy (n = 1). Repeated bronchoscopy rate was 8% (n = 5) and we had no mortality. This recently recognized aspiration hazard can be minimized by using adhesive bands or snap fasteners, instead of pins, when wearing a turban.
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Vestuario , Cuerpos Extraños/diagnóstico por imagen , Inhalación , Adolescente , Adulto , Broncoscopía/métodos , Niño , Femenino , Tecnología de Fibra Óptica/métodos , Migración de Cuerpo Extraño/diagnóstico por imagen , Humanos , Islamismo , Radiografía , Estudios Retrospectivos , Factores de Riesgo , TurquíaRESUMEN
BACKGROUND: For over a decade, the laparoscopic adjustable gastric band (LAGB) was 1 of the most performed bariatric procedures in Europe. This study is a retrospective analysis with prospectively collected data of the experience in 1 specialized Dutch center with the adjustable gastric band over 14 years. METHODS: Between 1995 and 2003, 201 patients underwent an LAGB for morbid obesity in our hospital. Data on preoperative clinical characteristic, postoperative outcome and weight loss patterns, and co-morbidities for up to 18 years are presented and evaluated using the Bariatric Analysis and Reporting Outcome System (BAROS). RESULTS: Average follow-up was 13.6 (± 2.0) years (163 mo) and 99% of patients with complete follow-up. Two thirds of patients reached an excess weight loss (EWL)>50% at some point after LAGB placement. However, due to insufficient weight loss or complications in 53% of patients, the LAGB had to be removed or converted to a Roux-en-Y gastric bypass. Additionally, half of the remaining patients had disappointing results according to the BAROS score. In total, less than one quarter (22%) of patients had a functioning band with a good result after the follow-up period. Although initially the number of patients experiencing co-morbidities was reduced, most of them returned and a large number of patients developed new co-morbidities. Complications, other than weight regain, were numerous as 47% of patients experienced at least 1. In total, 204 reoperations were performed in 137 (68%) patients. Furthermore, patients who were lost to follow-up did almost twice as bad in terms of EWL compared to patients who had regular follow-up. CONCLUSION: Morbid obesity is a chronic disease that can be resolved with bariatric surgery. One of the treatment options is the LAGB, which in the short term shows good results in terms of EWL and co-morbidity reduction. In the long term, however, EWL and co-morbidity reduction are disappointing, and the LAGB does not seem to live up to expectations. Besides the decrease in EWL over time, the number of reoperations required is alarming. In total, less than a quarter of patients still had a functioning band after a mean 14 years of follow-up.
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Derivación Gástrica , Gastroplastia/efectos adversos , Laparoscopía , Obesidad Mórbida/cirugía , Adulto , Remoción de Dispositivos , Femenino , Estudios de Seguimiento , Gastroplastia/instrumentación , Humanos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/complicaciones , Reoperación , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Pérdida de Peso , Adulto JovenRESUMEN
BACKGROUND: Severely obese patients have an increased risk for developing metabolic complications such as type 2 diabetes mellitus (T2DM), dyslipidaemia (DL) and hypertension (HT). The aim of the present study is to research the effect of a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) on T2DM, HT and DL in the long-term. METHODS: Fifty-two out of 89 (58 %) adult severely obese patients with T2DM who had received a LRYGB between January 2000 and December 2008 were evaluated. Primary outcome of evaluation was remission of T2DM according to the definition of 2009 consensus statement. Complete remission was defined as achievement fasting plasma glucose (FPG) of <5.6 mmol/l (<100.8 mg/dL) and HbA1c <42 mmol/mol (<6.0 %)) without glucose-lowering medication for at least 1 year. Partial remission was defined as a FPG of 5.6-6.9 mmol/l (100.8-124.2 mg/dL) and HbA1c 42-48 mmol/mol (6.0-6.5 %), without glucose-lowering medication for at least 1 year. Remission of T2DM was considered if the patient met the criteria for complete or partial remission. Secondary outcomes were remission of HT, DL and changes in medication use. RESULTS: Patients had a mean age of 47.5 ± 9.6 years, body mass index of 46.6 ± 6.4 kg/m(2) and a mean duration of T2DM of 6.1 ± 5.4 years at the time of surgery. The mean post-operative follow-up period was 6.9 ± 2.3 years. At the end of the follow-up, mean weight loss was 60 ± 24 % excess weight loss (EWL) and 26 ± 10 % total body weight loss (TBWL). Mean HbA1c level had significantly decreased from 64.8 ± 19.7 mmol/mol to 46.4 ± 12.9 mmol/l (p < 0.0001). Overall medication use was reduced from 85 % to 37 % of the patients (p < 0.0001), while the number of insulin users was reduced from 40 % to 6 % (p < 0.0001). Nineteen percent of the patients had a relapse of T2DM during follow-up. Pre-operative HbA1ac level (odds ratio 0.911, p = 0.020) and duration of T2DM (odds ratio 0.637, p = 0.010) were independent risk factors for failed remission of T2DM. The number of patients with HT was significantly reduced from 73 % to 54 % (p = 0.042), and number of patients with DL was non-significantly decreased from 71 % to 54 % (p = 0.068). CONCLUSIONS: The laparoscopic RYGB operation results in a sustained EWL of 60 % (26 % TBWL) with 52 % long-term remission of T2DM. However, 19 % of the patients had a relapse of their T2DM. Furthermore, HT and DL improved markedly.
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Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Adulto , Glucemia , Diabetes Mellitus Tipo 2/complicaciones , Dislipidemias/complicaciones , Femenino , Hemoglobina Glucada/metabolismo , Humanos , Hipertensión/complicaciones , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/sangre , Obesidad Mórbida/complicaciones , Periodo Posoperatorio , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later weakness totally recovered and hematoma was absent on MRI.
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Symptomatic spontaneous spinal epidural hematoma(SSEH) is an uncommon cause of cord compression that commonly is considered as an indication for emergent surgical decompression. We aimed to investigate a patient with a SSEH that completely resolved clinically and radiographically, without surgical treatment. The patient presented three days after the sudden onset of back pain, numbness, and weakness. Magnetic Resonance Imaging (MRI) revealed a posterior thoracolumbar epidural hematoma extending from the level of T10 to L2 with significant cord compression. Decompression was recommended but he refused surgery and was managed conservatively. One month later, weakness totally recovered and hematoma was absent on MRI.