[Morphological markers of pathophysiological changes in the neuronal processes in the acute post-traumatic period of diffuse axonal injury]. / Morfologicheskie markery patofiziologicheskikh izmenenii otrostkov neironov v ostrom posttravmaticheskom periode diffuznogo aksonal'nogo povrezhdeniya mozga.

The purpose of the study was to establish morphological markers of pathophysiological changes in the neuronal processes of in the acute (up to 36 hours) post-traumatic period of diffuse axonal injury (DAI) for the purposes of expert practice. Histological examination of the body of corpus callosum of the corpses of 66 persons dead from DAI and of 25 persons dead from various non-violent and violent causes, excluding head trauma, was performed (control group). Morphological markers of specific pathophysiological changes in the neuronal process were established by light microscopy with the use of immunohistochemical examination in acute period DAI. Uneven contours of the processes suggested displacement of cytoskeletal elements, areas of vacuolization of the cytoplasm of the processes suggested violation of intracellular transport caused by a change of permeability with preserved integrity of the process shell without mechanical separation of the process, uneven thickness (3.9 ± 1.6 µm) of the processes, varicose and cone-shaped thickening of them was a manifestation of focal edema of the neuronal process and compression of the cytoskeleton as a result of ion-enzymatic disorders, uneven coloration, areas of fragmentary compaction of neurofilaments indicated the zones of deformation and compression of the cytoskeleton, zones of granular-lumpy decay and fibrillolysis of neurofilaments indicated destruction of the cytoskeleton. Changes in the neuronal processes are a manifestation of a polyethological general pathological process and are not a differential diagnostic criterion of DAI.

[Expert errors in formulating a forensic diagnosis and conclusions in cases of diffuse axonal brain damage]. / Ekspertnye oshibki pri formulirovanii sudebno-meditsinskogo diagnoza i vyvodov v sluchayakh diffuznogo aksonal'nogo povrezhdeniya mozga.

The study objective is to review expert errors in the wording of a post-mortem diagnosis and expert conclusions in cases of traumatic brain injury with diffuse axonal brain damage. We reviewed 50 corpse examinations of those who died from a traumatic brain injury with diffuse axonal brain damage. A retrospective analysis of the results of expert examinations, the structure of the post-mortem forensic diagnosis, and the validity of expert conclusions showed that expert errors were made in 30% of cases. In 93% of cases, the errors were epistemological due to the lack of a scientifically based methodological approach to the expert opinion on a particular mechanism for the development of traumatic brain injury with diffuse axonal brain damage; and lack of professional expertise. A case is provided demonstrating the most common expert errors in the examination of this type of traumatic brain injury.

[Methodology for forensic diagnosis of diffuse axonal injury]. / Metodologiya sudebno-meditsinskoi diagnostiki diffuznogo aksonal'nogo povrezhdeniya golovnogo mozga.

An original methodological approach for forensic diagnostics of diffuse axonal injury (DAI) was developed based on the comprehensive study results. The approach is based on the algorithm of expert actions, including utilizing the developed rational methods set to identify pathognomonic morphological features using accessible and effective histological techniques. Also, the approach includes ways of analysis and estimation of these features. The proposed methodological approach aims to provide an objective diagnosis of this type of traumatic brain injury (TBI) and establish the age of its acute post-traumatic period. The known and generally accepted definitions of DAI and TBI are clarified.

[Problems of forensic diagnosis of diffuse axonal brain injury in the acute post-traumatic period]. / Problemy sudebno-meditsinskoi diagnostiki ostrogo perioda diffuznogo aksonal'nogo povrezhdeniya golovnogo mozga.

The article refers to actual problems of forensic diagnostics of diffuse axonal brain injury in the acute post-traumatic period, that is of particular importance in the case of head trauma in conditions of non-evidence. To solve the existing problems, it is necessary to conduct a comprehensive study aimed at improving the diffuse axonal brain injury examination by developing a unified methodological approach to running the forensic medical diagnostics of this form of traumatic brain injury and determining the duration of the acute (up to three days) post-traumatic period.

[Postmortem diagnostic of diffuse axonal injury considering histoarchitectonic of the corpus callosum]. / Posmertnaya diagnostika diffuznogo aksonal'nogo povrezhdeniya s uchetom gistoarkhitektoniki mozolistogo tela.

The results of studying the morphological signs of diffuse axonal injury (DAI) postmortem diagnosis in the brain are presented. It was investigated the histoarchitectonics of the corpus callosum in various types of non-violent and violent death. In the indusium griseum of the corpus callosum, neurons were identified; the features of the morphology and the interposition of the neurons processes, glia and vessels in various parts of the corpus callosum were studied. Taking into account the revealed architectonics of the corpus callosum, changes in DAI were determined. It was found that the main diagnostically significant morphological sign of DAI is hemorrhages localized in the trunk and indusium griseum on sagittal corpus callosum sections, which may be important in solving expert questions about the morphogenesis of hemorrhages in the corpus callosum.

[Diagnostic mistakes in diffuse axonal brain injury]. / Oshibki pri diagnostike diffuznogo aksonal'nogo povrezhdeniya mozga.

Based on the study results it were identified and systematized the most common deficiencies and mistakes that negatively affect the diagnosis of diffuse axonal brain injury and its genesis detection in the early post-traumatic period. It makes possible to organize correctly the diagnostic process and prevent an erroneous assessment of morphological changes in the brain during the examination of traumatic brain injury.

[Application of immunohistochemical study for the verification of diffuse axonal injury and determination of cause-and-effect relationships]. / Primenenie immunogistokhimicheskogo issledovaniia dlia verifikatsii diffuznogo aksonal'nogo povrezhdeniia i ustanovleniia prichinno-sledstvennykh sviazei.

Aim of this study is to establish a possibility of finding morphologic signs of diffuse axonal injury early after the injury. Use of immunohistochemical examination of the brain to detect protein ß-APP made it possible not only to diagnose this condition correctly, but also to reasonably and categorically answer the question of a causal relationship between causing damage and the onset of death.

Integrated Proteomics and Metabolomic Analyses of Plasma Injury Biomarkers in a Serious Brain Trauma Model in Rats.

Diffuse axonal injury (DAI) is a prevalent and serious brain injury with significant morbidity and disability. However, the underlying pathogenesis of DAI remains largely unclear, and there are still no objective laboratory-based tests available for clinicians to make an early diagnosis of DAI. An integrated analysis of metabolomic data and proteomic data may be useful to identify all of the molecular mechanisms of DAI and novel potential biomarkers. Therefore, we established a rat model of DAI, and applied an integrated UPLC-Q-TOF/MS-based metabolomics and isobaric tag for relative and absolute quantitation (iTRAQ)-based proteomic analysis to obtain unbiased profiling data. Differential analysis identified 34 metabolites and 43 proteins in rat plasma of the injury group. Two metabolites (acetone and 4-Hydroxybenzaldehyde) and two proteins (Alpha-1-antiproteinase and Alpha-1-acid glycoprotein) were identified as potential biomarkers for DAI, and all may play important roles in the pathogenesis of DAI. Our study demonstrated the feasibility of integrated metabolomics and proteomics method to uncover the underlying molecular mechanisms of DAI, and may help provide clinicians with some novel diagnostic biomarkers and therapeutic targets.

Prognostic value of corpus callosum injuries in severe head trauma.

BACKGROUND: This study was performed to investigate the relationship between corpus callosum (CC) injury and prognosis in traumatic axonal injury (TAI). METHOD: We retrospectively reviewed 264 patients with severe head trauma who underwent a conventional MR imaging in the first 60 days after injury. They were selected from a prospectively collected database of 1048 patients with severe head trauma admitted in our hospital. TAI lesions were defined as areas of increased signal intensity on T2 and FLAIR or areas of decreased signal on gradient-echo T2. We attempted to determine whether any MR imaging findings of TAI lesions at CC could be related to prognosis. Neurological impairment was assessed at 1 year after injury by means of GOS-E (good outcome being GOS-E 4/5 and bad outcome being GOS-E <4). We adjusted the multivariable analysis for the prognostic factors according to the IMPACT studies: the Core model (age, motor score at admission, and pupillary reactivity) and the Extended model (including CT information and second insults). RESULTS: We found 97 patients (37 %) with TAI at CC and 167 patients (63 %) without CC lesions at MR. A total of 62 % of the patients with CC lesions had poor outcome, whereas 38 % showed good prognosis. The presence of TAI lesions at the corpus callosum was associated with poor outcome 1 year after brain trauma (p < 0.001, OR 3.8, 95 % CI: 2.04-7.06). The volume of CC lesions measured on T2 and FLAIR sequences was negatively correlated with the GOS-E after adjustment for independent prognostic factors (p = 0.01, OR 2.23, 95 % CI:1.17-4.26). Also the presence of lesions at splenium was statistically related to worse prognosis (p = 0.002, OR 8.1, 95 % CI: 2.2-29.82). We did not find statistical significance in outcome between hemorrhagic and non-hemorrhagic CC lesions. CONCLUSIONS: The presence of CC is associated with a poor outcome. The total volume of the CC lesion is an independent prognostic factor for poor outcome in severe head trauma.

Revisiting Grade 3 Diffuse Axonal Injury: Not All Brainstem Microbleeds are Prognostically Equal.

BACKGROUND: Recovery of functional independence is possible in patients with brainstem traumatic axonal injury (TAI), also referred to as "grade 3 diffuse axonal injury," but acute prognostic biomarkers are lacking. We hypothesized that the extent of dorsal brainstem TAI measured by burden of traumatic microbleeds (TMBs) correlates with 1-year functional outcome more strongly than does ventral brainstem, corpus callosal, or global brain TMB burden. Further, we hypothesized that TMBs within brainstem nuclei of the ascending arousal network (AAN) correlate with 1-year outcome. METHODS: Using a prospective outcome database of patients treated for moderate-to-severe traumatic brain injury at an inpatient rehabilitation hospital, we retrospectively identified 39 patients who underwent acute gradient-recalled echo (GRE) magnetic resonance imaging (MRI). TMBs were counted on the acute GRE scans globally and in the dorsal brainstem, ventral brainstem, and corpus callosum. TMBs were also mapped onto an atlas of AAN nuclei. The primary outcome was the disability rating scale (DRS) score at 1 year post-injury. Associations between regional TMBs, AAN TMB volume, and 1-year DRS score were assessed by calculating Spearman rank correlation coefficients. RESULTS: Mean ± SD number of TMBs was: dorsal brainstem = 0.7 ± 1.4, ventral brainstem = 0.2 ± 0.6, corpus callosum = 1.8 ± 2.8, and global = 14.4 ± 12.5. The mean ± SD TMB volume within AAN nuclei was 6.1 ± 18.7 mm3. Increased dorsal brainstem TMBs and larger AAN TMB volume correlated with worse 1-year outcomes (R = 0.37, p = 0.02, and R = 0.36, p = 0.02, respectively). Global, callosal, and ventral brainstem TMBs did not correlate with outcomes. CONCLUSIONS: These findings suggest that dorsal brainstem TAI, especially involving AAN nuclei, may have greater prognostic utility than the total number of lesions in the brain or brainstem.

SNTF immunostaining reveals previously undetected axonal pathology in traumatic brain injury.

Diffuse axonal injury (DAI) is a common feature of severe traumatic brain injury (TBI) and may also be a predominant pathology in mild TBI or "concussion". The rapid deformation of white matter at the instant of trauma can lead to mechanical failure and calcium-dependent proteolysis of the axonal cytoskeleton in association with axonal transport interruption. Recently, a proteolytic fragment of alpha-II spectrin, "SNTF", was detected in serum acutely following mild TBI in patients and was prognostic for poor clinical outcome. However, direct evidence that this fragment is a marker of DAI has yet to be demonstrated in either humans following TBI or in models of mild TBI. Here, we used immunohistochemistry (IHC) to examine for SNTF in brain tissue following both severe and mild TBI. Human severe TBI cases (survival <7d; n = 18) were compared to age-matched controls (n = 16) from the Glasgow TBI archive. We also examined brains from an established model of mild TBI at 6, 48 and 72 h post-injury versus shams. IHC specific for SNTF was compared to that of amyloid precursor protein (APP), the current standard for DAI diagnosis, and other known markers of axonal pathology including non-phosphorylated neurofilament-H (SMI-32), neurofilament-68 (NF-68) and compacted neurofilament-medium (RMO-14) using double and triple immunofluorescent labeling. Supporting its use as a biomarker of DAI, SNTF immunoreactive axons were observed at all time points following both human severe TBI and in the model of mild TBI. Interestingly, SNTF revealed a subpopulation of degenerating axons, undetected by the gold-standard marker of transport interruption, APP. While there was greater axonal co-localization between SNTF and APP after severe TBI in humans, a subset of SNTF positive axons displayed no APP accumulation. Notably, some co-localization was observed between SNTF and the less abundant neurofilament subtype markers. Other SNTF positive axons, however, did not co-localize with any other markers. Similarly, RMO-14 and NF-68 positive axonal pathology existed independent of SNTF and APP. These data demonstrate that multiple pathological axonal phenotypes exist post-TBI and provide insight into a more comprehensive approach to the neuropathological assessment of DAI.

Imaging assessment of traumatic brain injury.

Traumatic brain injury (TBI) constitutes injury that occurs to the brain as a result of trauma. It should be appreciated as a heterogeneous, dynamic pathophysiological process that starts from the moment of impact and continues over time with sequelae potentially seen many years after the initial event. Primary traumatic brain lesions that may occur at the moment of impact include contusions, haematomas, parenchymal fractures and diffuse axonal injury. The presence of extra-axial intracranial lesions such as epidural and subdural haematomas and subarachnoid haemorrhage must be anticipated as they may contribute greatly to secondary brain insult by provoking brain herniation syndromes, cranial nerve deficits, oedema and ischaemia and infarction. Imaging is fundamental to the management of patients with TBI. CT remains the imaging modality of choice for initial assessment due to its ease of access, rapid acquisition and for its sensitivity for detection of acute haemorrhagic lesions for surgical intervention. MRI is typically reserved for the detection of lesions that may explain clinical symptoms that remain unresolved despite initial CT. This is especially apparent in the setting of diffuse axonal injury, which is poorly discerned on CT. Use of particular MRI sequences may increase the sensitivity of detecting such lesions: diffusion-weighted imaging defining acute infarction, susceptibility-weighted imaging affording exquisite data on microhaemorrhage. Additional advanced MRI techniques such as diffusion tensor imaging and functional MRI may provide important information regarding coexistent structural and functional brain damage. Gaining robust prognostic information for patients following TBI remains a challenge. Advanced MRI sequences are showing potential for biomarkers of disease, but this largely remains at the research level. Various global collaborative research groups have been established in an effort to combine imaging data with clinical and epidemiological information to provide much needed evidence for improvement in the characterisation and classification of TBI and in the identity of the most effective clinical care for this patient cohort. However, analysis of collaborative imaging data is challenging: the diverse spectrum of image acquisition and postprocessing limits reproducibility, and there is a requirement for a robust quality assurance initiative. Future clinical use of advanced neuroimaging should ensure standardised approaches to image acquisition and analysis, which can be used at the individual level, with the expectation that future neuroimaging advances, personalised to the patient, may improve prognostic accuracy and facilitate the development of new therapies.

[Proteomic Analysis of Rat Brain Stem with DAI by MALDI-TOF-MS].

OBJECTIVE: To establish a diagnostic model for diffuse axonal injury (DAI) by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS). To screen the proteins or peptides associated with DAI for providing the biomarkers with theoretic foundation. METHODS: Fifteen male Sprague-Dawley rats were randomly divided into DAI group (n = 10) and control group (n = 5). The protein or peptide expression profiles of rat brain stem were detected by MALDI-TOF-MS. ClinProTools 2.2 software was used to find specific peaks, and a diagnostic model was established by the genetic algorithm. RESULTS: There were significant differences in 61 peaks of DAI group (P < 0.05), 9 peaks were down-regulated and 52 up-regulated. The diagnostic model was established based on 5 different peaks. The specificity and sensitivity of cross validation was 96.14% and 95.98%; while the specificity and sensitivity of blind validation showed was 73.33% and 70.00%, respectively. CONCLUSION: A specific and sensitive diagnostic model of DAI can be established by MALDI-TOF-MS to provide a potential value for determining DAI in forensic practice.

Diffuse Axonal Injury-A Distinct Clinicopathological Entity in Closed Head Injuries.

The knowledge about the diffuse axonal injury (DAI) as a clinicopathological entity has matured in the last 30 years. It has been defined clinically (immediate and prolonged unconsciousness leading to death or severe disability) and pathologically (the triad of DAI specific changes). In terms of its biomechanics, DAI is occurring as a result of acceleration forces of longer duration and has been fully reproduced experimentally.In the process of diagnosing DAI, the performance of a complete forensic neuropathological examination is essential and the immunohistochemistry method using antibodies against ß-amyloid precursor protein (ß-APP) has been proved to be highly sensitive and specific, selectively targeting the damaged axons.In this review, we are pointing to the significant characteristics of DAI as a distinct clinicopathological entity that can cause severe impairment of the brain function, and in the forensic medicine setting, it can be found as the concrete cause of death. We are discussing not only its pathological feature, its mechanism of occurrence, and the events on a cellular level but also the dilemmas about DAI that still exist in science: (1) regarding the strict criteria for its diagnosis and (2) regarding its biomechanical significance, which can be of a big medicolegal importance.

Detection of blast-related traumatic brain injury in U.S. military personnel.

BACKGROUND: Blast-related traumatic brain injuries have been common in the Iraq and Afghanistan wars, but fundamental questions about the nature of these injuries remain unanswered. METHODS: We tested the hypothesis that blast-related traumatic brain injury causes traumatic axonal injury, using diffusion tensor imaging (DTI), an advanced form of magnetic resonance imaging that is sensitive to axonal injury. The subjects were 63 U.S. military personnel who had a clinical diagnosis of mild, uncomplicated traumatic brain injury. They were evacuated from the field to the Landstuhl Regional Medical Center in Landstuhl, Germany, where they underwent DTI scanning within 90 days after the injury. All the subjects had primary blast exposure plus another, blast-related mechanism of injury (e.g., being struck by a blunt object or injured in a fall or motor vehicle crash). Controls consisted of 21 military personnel who had blast exposure and other injuries but no clinical diagnosis of traumatic brain injury. RESULTS: Abnormalities revealed on DTI were consistent with traumatic axonal injury in many of the subjects with traumatic brain injury. None had detectable intracranial injury on computed tomography. As compared with DTI scans in controls, the scans in the subjects with traumatic brain injury showed marked abnormalities in the middle cerebellar peduncles (P<0.001), in cingulum bundles (P=0.002), and in the right orbitofrontal white matter (P=0.007). In 18 of the 63 subjects with traumatic brain injury, a significantly greater number of abnormalities were found on DTI than would be expected by chance (P<0.001). Follow-up DTI scans in 47 subjects with traumatic brain injury 6 to 12 months after enrollment showed persistent abnormalities that were consistent with evolving injuries. CONCLUSIONS: DTI findings in U.S. military personnel support the hypothesis that blast-related mild traumatic brain injury can involve axonal injury. However, the contribution of primary blast exposure as compared with that of other types of injury could not be determined directly, since none of the subjects with traumatic brain injury had isolated primary blast injury. Furthermore, many of these subjects did not have abnormalities on DTI. Thus, traumatic brain injury remains a clinical diagnosis. (Funded by the Congressionally Directed Medical Research Program and the National Institutes of Health; ClinicalTrials.gov number, NCT00785304.).

[The histological confirmation of diffuse axonal injury in severe brain injury survivors]. / Der histologische Nachweis des diffusen axonalen Hirnschadens bei Überlebenden schwerer Schädel-Hirntraumen.

Diffuse axonal injury (DAI) plays a major role after traumatic brain injury (TBI). Its imaging is based on computed tomography (CT) or magnetic resonance imaging (MRI). However, DAI is a histological diagnosis. Histopathological findings on survival after TBI are very rare. Hence, it is unclear whether the neuroradiological findings are of clinical relevance. Cerebral specimens were taken in 24 patients with TBI requiring surgery. The presence of histopathological evidence for DAI was evaluated. Specimens were taken from an extracranial brain prolapse (n = 2) and from peripheral parts of a brain contusion (n = 22). Histological findings were correlated to the clinical course and the neurological status. A clinical follow-up was carried out 6 months after the surgery using the Glasgow Outcome Score (GOS). The study was approved by the local ethics committee. Specimens taken were temporal (n = 11), frontal (n = 8), parietal (n = 4) and cerebellar (n = 1). The incidence of DAI within these specimens was 30% (7 with DAI, 17 without DAI). DAI was verifiable up to 3 days after trauma. There was no correlation between DAI and Marshall classification in CT. The period of coma was longer in subjects with DAI. There was no difference in GOS in the case of a verified DAI. These results enforce the prognostic and neuroradiologic relevance of DAI. However, it is debatable whether the pathomorphologic findings in CT or MRI represent the histological findings of DAI. We suggest a multicentre study for further clarification.

Molecular biomarkers of diffuse axonal injury: recent advances and future perspectives.

INTRODUCTION: Diffuse axonal injury (DAI), with high mortality and morbidity both in children and adults, is one of the most severe pathological consequences of traumatic brain injury. Currently, clinical diagnosis, disease assessment, disability identification, and postmortem diagnosis of DAI is mainly limited by the absent of specific molecular biomarkers. AREAS COVERED: In this review, we first introduce the pathophysiology of DAI, summarized the reported biomarkers in previous animal and human studies, and then the molecular biomarkers such as ß-Amyloid precursor protein, neurofilaments, S-100ß, myelin basic protein, tau protein, neuron-specific enolase, Peripherin and Hemopexin for DAI diagnosis is summarized. Finally, we put forward valuable views on the future research direction of diagnostic biomarkers of DAI. EXPERT OPINION: In recent years, the advanced technology has ultimately changed the research of DAI, and the numbers of potential molecular biomarkers was introduced in related studies. We summarized the latest updated information in such studies to provide references for future research and explore the potential pathophysiological mechanism on diffuse axonal injury.

Neuro-ophthalmic deficits after head trauma.

Head trauma can injure the afferent and/or efferent visual systems, resulting in neuro-ophthalmic deficits. When assessing afferent pathway injuries, a stepwise approach to evaluating visual acuity, pupils, color perception, and visual fields is critical. Traumatic optic neuropathy is of especial importance and its management must be tailored on a case-by-case basis. Efferent pathway injuries should be assessed with attention to abnormalities of ocular alignment and motility, which may occur as isolated deficits or as part of a recognizable syndrome. Concussion or diffuse axonal injuries may also affect ophthalmologic function. Here, we review the extant literature describing the assessment and acute treatment of traumatic neuro-ophthalmic deficits.

Susceptibility-weighted imaging in patient with consciousness disturbance after traffic accident.

Both diffuse axonal injury (DAI) and fat embolism syndrome could be the cause of altered consciousness in patients who suffered from traffic accident. In some situations, distinguishing DAI from fat embolism syndrome may be difficult because routine brain imaging could not detect the lesions. Susceptibility weighted imaging is sensitive to detect petechial hemorrhages in cerebral fat embolism and DAI. The areas most vulnerable to DAI are the cerebral gray-white matter junction, splenium of the corpus callosum, and dorsolateral brainstem. However, cerebral and cerebellar white matter and splenium of corpus callosum are the areas most vulnerable to cerebral fat embolism. In additional to history, clinical manifestation, and prognosis, evaluating the distribution of hypointense lesions in susceptibility-weighted imaging could be useful to differentiate these 2 conditions.

[Disability identification for cases with clinical diagnosis of diffuse axonal injury due to traffic accidents: a study of 89 cases].

OBJECTIVE: To study the disability identification for cases with clinical diagnosis of diffuse axonal injury (DAI) due to traffic accidents, and to explore the possible effects of DAI on identification results. METHODS: Five hundred and fifty-six cases of cerebral injury due to traffic accidents were collected, including 467 cases diagnosed with cerebral contusion or laceration and 89 cases diagnosed with DAI. The identification results of different groups with diagnosis of DAI diagnosis, diagnosis of DAI with cerebral contusion (laceration), and diagnosis of cerebral contusion or laceration without DAI were compared and statistically analyzed, based on the results of CT and MRI re-review. RESULTS: The disability identification levels in DAI group (20 cases), DAI group (69 cases) with cerebral contusion (laceration) and DAI group (467 cases) not complicated by cerebral contusion (laceration) were 7.72 +/- 1.09, 7.78 +/- 1.11, and 8.86 +/- 0.66, respectively. The disability levels of the two groups diagnosed with DAI were higher than those of the group without DAI diagnosis (P < 0.05). CONCLUSION: Patients with DAI diagnosis might have more severe cerebral injury. In the identification process, one should pay attention to the possible missed diagnosis and misdiagnosis, and meanwhile avoid relying on those evidences provided only by CT and MRI.