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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The mortality statistics of severe traumatic brain injury &#40;TBI&#41; have changed very little in the last 20 years&#46; The principal mechanism leading to death is uncontrolled intracranial hypertension and the ischemic brain damage it produces&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The cause of such intracranial hypertension is the increase in brain volume triggered by different mechanisms&#44; including vasogenic or extracellular brain edema secondary to rupture of the blood&#8211;brain barrier &#40;BBB&#41; and cytotoxic or intracellular edema&#44; associated to ischemia&#46; Intracellular edema is considered to be the main contributor to brain swelling after closed trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diffusion-weighted magnetic resonance imaging &#40;DWMR&#41; produces a signal with an intensity proportional to the diffusion of water molecules in the tissues&#46; The signal depends on the diffusion capacity of the molecules&#44; on the interactions among them&#44; and on the obstacles facing molecular movement&#46; The intensity of the signal can be quantified by the apparent diffusion coefficient &#40;ADC&#41;&#44; which is calculated by means of the following formula&#58; ADC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#40;1&#47;<span class="elsevierStyleItalic">b</span>&#41;<span class="elsevierStyleHsp" style=""></span>log&#40;S1&#47;S0&#41;&#44; where &#8220;<span class="elsevierStyleItalic">b</span>&#8221; is a factor that depends on the strength and duration of the pulses applied to increase diffusion&#44; &#8220;S1&#8221; is the intensity of the diffusion-weighted signal&#44; and &#8220;S0&#8221; is the intensity of the non-diffusion-weighted signal&#46; If this formula is applied to each voxel &#40;three-dimensional graphic element&#41;&#44; the end result is a map or image in which the intensity of the signal is proportional to the ADC of each region or tissue examined&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Conventional magnetic resonance imaging &#40;MRI&#41; is unable to distinguish between types of edema based on the intensity of the signal&#59; both types of edema&#44; cytotoxic and vasogenic&#44; produce a hyperintense signal in T2-weighted sequences&#46; In contrast&#44; DWMR differentiates cytotoxic edema&#44; which is characterized by an increase in intracellular fluid uptake&#44; resulting in low ADC values&#46; The ADC is reduced as a consequence of restricted water molecule diffusion produced by the membranes and organelles within the cell&#44; and by the increase in viscosity&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In contrast&#44; in vasogenic edema&#44; the fluid displaces from the vessels to the extracellular compartment&#44; which therefore increases in size and allows the molecules to move more freely&#46; This produces different effects in the magnetic resonance image&#58; either high signal intensity in the ADC and DWMR maps or&#44; less frequently&#44; high signal intensity in the ADC map and low signal intensity in the DWMR image &#40;facilitated diffusion&#41;&#46; These changes in signal intensity are generally located around a focal parenchymal lesion&#44; for example&#44; a hematoma&#44; since the blood clot exerts an osmotic effect upon the surrounding brain tissues&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">To date&#44; the main application of DWMR has been the detection of acute cerebral infarction&#46; In this context&#44; it is able to detect stroke earlier than any other technique&#44; thanks to its high sensitivity&#44; and DWMR is moreover able to predict the infarct size and assess the patient prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">DWMR has been used in patients with TBI to evaluate diffuse axonal injury &#40;DAI&#41;&#44; in view of its greater sensitivity compared with other conventional techniques &#40;T2 and FLAIR sequencing&#41; in the acute phase after trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> In addition&#44; the volume of the lesion detected with this technique is correlated to clinical outcome&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Since DWMR is able to distinguish between extracellular and intracellular edema&#44; it could be used to evaluate the contribution of both types of edema to the damage observed in patients with severe TBI&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Furthermore&#44; the early detection of secondary ischemic lesions in severe TBI would be of great importance&#44; given their impact upon morbidity-mortality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The present study analyzes the ADC values in a series of patients with focal trauma and their correlation to initial clinical severity and ultimate patient prognosis or outcome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Design</span><p id="par0045" class="elsevierStylePara elsevierViewall">A descriptive&#44; observational case series is presented&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients and clinical data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The study involved patients with severe TBI&#44; defined by a Glasgow coma score of fewer than 9 without sedation in the first 24<span class="elsevierStyleHsp" style=""></span>h after injury&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> admitted to the Intensive Care Unit &#40;ICU&#41; of Canarias University Hospital &#40;Spain&#41;&#44; and with no contraindications to transfer or MRI study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The traumatisms were categorized according to the initial computed tomography &#40;CT&#41; scan&#44; based on the Marshall classification<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All patients were subjected to early surgical evacuation of space-occupying lesions&#44; with hemodynamic&#44; respiratory and intracranial pressure monitoring&#46; Intracranial hypertension was managed using osmotherapy&#44; optimized hyperventilation&#44; and occasionally barbiturates&#46; The outcome data were evaluated based on the Glasgow Outcome Score &#40;GOS&#41; at discharge from the ICU and after 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Imaging techniques and analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The MRI studies were made using a 1&#46;5<span class="elsevierStyleHsp" style=""></span>Tesla system &#40;General Electric&#41;&#46; The imaging protocol comprised the following sequences&#58; a T1-weighted sagittal sequence&#44; a T1-weighted axial sequence&#44; a T2-weighted axial sequence&#44; and a fluid attenuated inversion recovery &#40;FLAIR&#41; sequence&#46; The diffusion-weighted images were obtained using an echo-planar pulse sequence with the following characteristics&#58; TR 10&#44;000<span class="elsevierStyleHsp" style=""></span>ms&#44; TE 126&#46;9<span class="elsevierStyleHsp" style=""></span>ms&#44; <span class="elsevierStyleItalic">b</span> values 1000<span class="elsevierStyleHsp" style=""></span>s&#47;mm<span class="elsevierStyleSup">2</span> in the three spatial dimensions&#46; By combining the three sets of images we obtained an isotropic image conforming a map of the mean ADC values&#46; Image processing for calculation of ADC was made using Functool 2000<span class="elsevierStyleSup">&#174;</span> software&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In order to analyze the image&#44; we established a measurement zone in each lesion&#44; selecting the section where the diffusion-weighted image presented a greater signal intensity&#44; and within this image we selected a bidimensional region of interest &#40;ROI&#41; where ADC was measured&#46; The core of the hemorrhagic lesions was excluded from the calculation&#46; In the diffuse lesions we measured ADC in one or both hemispheres&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The normal reference values for the mean ADC were those obtained by Helenius et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> who measured the values of 18 neuroanatomical regions in 18 healthy volunteers&#46; The values are the following&#58; &#40;890<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s in the cortical gray matter &#40;range 780&#8211;1090<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#44; &#40;700<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s in the white matter &#40;range 620&#8211;790<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#44; &#40;750<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s in the basal ganglia &#40;range 640&#8211;830<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#44; and &#40;730<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s in the thalamus &#40;range 670&#8211;820<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span><span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>&#47;s&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Continuous variables are reported as the mean and standard deviation&#44; while discrete variables are reported as absolute and relative frequencies&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">We recorded 71 patients with severe TBI admitted to the ICU between November 2001 and October 2004&#46; DWMR was performed in 23 of them&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> show the epidemiological and clinical data&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Regarding the types of injuries&#44; surgically evacuated space-occupying lesions were the most frequent presentation&#44; followed by type II lesions&#46; There were no type III diffuse lesions in our series&#46; Seven lesions were defined as diffuse axonal injury &#40;DAI&#41; on the basis of their magnetic resonance location in the subcortical white matter&#44; corpus callosum or brainstem&#44; together with persistent coma &#40;Glasgow coma score<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>9&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding outcome as determined by the GOS&#44; 70&#37; of the patients had died or were in a vegetative state or seriously disabled &#40;poor prognosis&#41; at discharge from the ICU&#44; versus 43&#37; after 6 months&#46; These results are reported in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Imaging data</span><p id="par0105" class="elsevierStylePara elsevierViewall">Attempts were made to perform MRI as soon as possible after admission&#44; though in only four patients was the exploration made within the first 24<span class="elsevierStyleHsp" style=""></span>h&#44; while 12 patients &#40;14 lesions&#41; were subjected to MRI evaluation within the first 48<span class="elsevierStyleHsp" style=""></span>h&#46; In the rest of the cases the timing of the study was highly varied due to different reasons&#8211;fundamentally patient instability and the distance to the MRI unit&#44; which according to the physician in charge questioned the usefulness of the study&#46; In any case&#44; we finally decided to analyze all the studies&#44; even if performed over a broad interval of time&#46; Globally&#44; MRI was performed at an average of 101&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>111&#46;80<span class="elsevierStyleHsp" style=""></span>h &#40;range 10&#8211;360&#41; after trauma&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We selected 26 ROIs for analysis in the images of the 23 patients&#44; and documented the ADC in each of them&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the mean values globally and according to the type of lesion&#46; An increase in diffusion in the non-evacuated space-occupying lesions was observed when compared with the rest of the types of injuries and with the normal values&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The ADC values showed a progressive increase with the time from trauma&#8211;ADC in the first 48<span class="elsevierStyleHsp" style=""></span>h being lower than the values recorded later in time &#40;898&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>205&#46;3&#47;1026&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>164&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The prognosis &#40;outcome&#41; was considered poor if the patient had died after 6 months or was in a vegetative state or seriously disabled&#44; and good in the case of patients with moderate or slight disability&#44; or no disability&#46; As can be seen in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#44; the patients with a poor prognosis had lower ADC values than those with a good prognosis&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the outcomes according to the ADC findings at the three measurement timepoints&#46; It should be noted that both in the global results and on considering only the measurements made in the first 24<span class="elsevierStyleHsp" style=""></span>h and those made in the first 72<span class="elsevierStyleHsp" style=""></span>h&#44; the ADC values were always lower in the patients with a poor prognosis&#8211;though the sample size was too small to allow the drawing of firm conclusions&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Summary of results</span><p id="par0125" class="elsevierStylePara elsevierViewall">The ADC values were higher in patients with contusions than in those with other types of injuries&#46; In patients with a poor prognosis&#44; the ADC values were lower&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">The diffusion of water in the brain tissues&#44; measured by MRI techniques&#44; was greater in contusions than in other types of injuries&#44; which could be an expression of vasogenic edema&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Findings of other studies&#58; regarding the changes in ADC after traumatism&#44; experimental studies in animals have yielded contradictory results&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#44; where some authors have reported an increase in diffusion as a result of vasogenic edema<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> while others describe a two-phase response<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> or even significantly diminished diffusion values&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Some studies only report changes when secondary damage is added&#44; with diffusion decreasing as a result of cytotoxic edema&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;29</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The apparently conflicting results of these studies could be attributed to the diversity of lesion models used&#44; the different MRI techniques employed for measurement&#44; and the lack of distinction between cortical lesions and diffuse axonal injury&#44; which could involve different mechanisms and evolutive patterns&#46; In animal studies&#44; the ADC values are generally measured in the first minutes or hours after injury&#44; while in humans ADC is measured from hours to days after trauma in many cases&#46; This could explain the different ADC variation profiles observed&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Human studies have focused on three aspects&#58; the identification of diffuse axonal injury and its diffusion characteristics&#59; analysis of the type of edema in the brain lesions&#59; and evaluation of the usefulness of DWMR in predicting the clinical outcome&#46; Many authors agree that DWMR is more sensitive than other conventional MRI techniques in detecting DAI&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#8211;32</span></a> but the observed diffusion changes vary&#46; In a study of 116 patients with DAI&#44; 64&#37; of the lesions had diminished ADC values while 34&#37; presented increased values&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Liu reported decreased diffusion values in 9 patients with DAI&#46; In these patients&#44; the ADC values decreased significantly in typical DAI observed in conventional MRI images&#44; from as early as one day after injury&#44; and this decrease persisted for up to 18 days&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> On the other hand&#44; the significance of these changes is also controversial&#46; In this context&#44; some authors consider that lesions with low ADC values are indicative of severe brain damage and could predict the long-term outcome&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;32</span></a> Schaefer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> studied 26 patients with DAI using DWMR&#46; They observed a strong correlation between the volume of the signal intensity alteration in the diffusion-weighted images and initial clinical severity&#44; but this correlation did not improve on only considering lesions with decreased ADC values&#46; Hou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> in turn analyzed the changes in diffusion in 37 adults with brain injuries&#46; Patients with more serious injuries were found to have ADC values significantly different from those of the controls&#44; and patients with an unfavorable prognosis presented significantly higher ADC values than individuals with a favorable prognosis or the controls&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In our series we identified 7 cases of DAI&#44; with mean ADC values above normal&#46; After 6 months&#44; three of these patients had a poor prognosis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Regarding the type of edema&#44; some authors consider that the distinction between intra- and extracellular edema is of key prognostic and therapeutic importance&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35&#8211;37</span></a> In a series of patients with traumatisms in which the fluid content and ADC were measured using MRI&#44; the authors observed an increase in tissue fluid associated with a decrease in ADC&#8211;thus suggesting predominant intracellular edema&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> though in this study the type of lesion and the time elapsed between trauma and MRI were not specified&#46; In a later study&#44; the same group<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> used MRI techniques to identify the type of edema that developed in 44 patients with serious brain injuries&#46; The patients with brain swelling showed an increased brain water content and low ADC values&#44; compared with the healthy volunteers&#46; The authors concluded that traumatic brain swelling appears to be predominantly cellular&#44; as suggested by the low ADC values and the high tissue water content&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Our patients predominantly presented mass-type lesions&#44; and the latter &#40;12 non-evacuated&#44; mixed-density contusions&#41; showed an increase in diffusion that could be an expression of vasogenic edematization&#44; even when only considering the images obtained in the first 48<span class="elsevierStyleHsp" style=""></span>h after injury&#46; Such lesions would correspond to type I injuries according to the classification proposed by Gasparetto&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> referred to traumatic brain injury patterns in DWMR&#47;ADC imaging&#46; According to this classification&#44; type I injuries consist of hyperintense images in diffusion-weighted imaging with an increase in ADC&#44; representing vasogenic edema&#46; Type II injuries in turn comprise hyperintense lesions in diffusion but with a decrease in ADC&#44; indicating cytotoxic edema&#44; while type III injuries correspond to central hemorrhagic lesions surrounded by a hyperintense area in the diffusion image and an increase in ADC&#46; It is important to note that in diffusion imaging of hemorrhagic lesions it is not clear whether low ADC values correspond to cytotoxic edema or to artifacts produced by extravasated blood&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Our patients with a poor outcome had lower ADC values than those with a good outcome&#46; Many studies have described different ADC values in patients with a poor prognosis compared with controls or patients with a good prognosis&#44; but there is little consensus regarding the pattern of change&#44; as reflected by the abovementioned studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;32&#44;34&#44;36&#8211;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Study limitations&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Of all the severe brain injury patients admitted to the ICU&#44; we were only able to use DWMR in 23 cases&#44; due to problems related to critical patient transfer&#44; which make it difficult to perform early and repeated MRI scans&#46; As a result&#44; our sample size was small and scanning covered a broad time interval&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In addition&#44; we had no cases of diffuse swelling for comparison with other types of injuries&#59; as a result&#44; our study fundamentally centers on focal injuries&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Another recognized limitation is the use of reference values cited in the literature&#44; instead of values referred to contemporaneous controls&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0195" class="elsevierStylePara elsevierViewall">The mean ADC values in the lesions were greater than the normal values and greater in contusions than in other types of injuries&#44; thus indicating that extracellular edema probably plays a dominant role in these lesions&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The ADC values were decreased in patients with a poor prognosis&#44; suggesting an association between ischemia and patient outcome&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Diffusion-weighted magnetic resonance imaging"
            1 => "Apparent diffusion coefficient"
            2 => "Echo-planar imaging"
            3 => "Brain injuries"
            4 => "Vasogenic brain edema"
            5 => "Cytotoxic brain edema"
            6 => "Glasgow Outcome Scale"
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            0 => "Resonancia magn&#233;tica de difusi&#243;n"
            1 => "Coeficiente de difusi&#243;n aparente"
            2 => "Imagen eco-planar"
            3 => "Lesiones cerebrales"
            4 => "Edema cerebral vasog&#233;nico"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the apparent diffusion coefficient &#40;ADC&#41; in a series of severe traumatic brain injuries&#44; their clinical and outcome features&#44; and possible implications&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A descriptive&#44; observational case-series study was carried out&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Patients and interventions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients with severe traumatic brain injuries &#40;TBIs&#41; admitted to the ICU were subjected to MRI study using a 1&#46;5<span class="elsevierStyleHsp" style=""></span>T scanner&#46; Diffusion-weighted images &#40;DWMR&#41; were obtained using the following echo-planar pulse sequence&#58; TR 10&#44;000<span class="elsevierStyleHsp" style=""></span>ms&#44; TE 126&#46;9<span class="elsevierStyleHsp" style=""></span>ms&#44; with b values 1000<span class="elsevierStyleHsp" style=""></span>s&#47;mm<span class="elsevierStyleSup">2</span> in the three spatial dimensions&#46; Combining the three sets of images&#44; an isotropic image conforming a map of the mean ADCs was obtained&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">DWMR was performed in 23 patients with severe TBI admitted to the ICU between 2001 and 2004&#46; In the MR images we selected 26 regions of interest &#40;ROIs&#41; where ADC was recorded&#46; We observed a clear increase in diffusion in non-treated space-occupying lesions versus other types of injuries and the normal values&#46; A poorer outcome was recorded in patients with lower ADC values&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mean ADC in the lesions was greater than the normal values and greater in contusions than in other types of injuries&#44; as an expression of extracellular edema&#46; ADCs were decreased in patients with a poor outcome&#44; suggesting an association between ischemia and the patient prognosis&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Describir el coeficiente de difusi&#243;n aparente &#40;CDA&#41; medido mediante resonancia magn&#233;tica potenciada en difusi&#243;n &#40;RMD&#41; en una serie de pacientes con traumatismo craneoencef&#225;lico &#40;TCE&#41; grave&#44; sus aspectos cl&#237;nicos y pron&#243;sticos y sus posibles implicaciones&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Dise&#241;o</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; descriptivo de serie de casos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Pacientes e intervenciones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pacientes con TCE grave&#44; ingresados en UCI que no presentan contraindicaciones para traslado y realizaci&#243;n de resonancia magn&#233;tica &#40;RM&#41;&#46; Se realiz&#243; RM usando un scanner de 1&#46;5<span class="elsevierStyleHsp" style=""></span>Tesla&#46; Las im&#225;genes potenciadas en difusi&#243;n se obtuvieron usando una secuencia de pulso eco-planar con las siguientes caracter&#237;sticas&#58; TR 10&#46;000<span class="elsevierStyleHsp" style=""></span>ms&#44; TE 126&#44;9<span class="elsevierStyleHsp" style=""></span>ms&#44; valores b 1&#46;000<span class="elsevierStyleHsp" style=""></span>s&#47;mm<span class="elsevierStyleSup">2</span> en las tres direcciones del espacio&#46; Combinando los tres sets de im&#225;genes se obtuvo una imagen isotr&#243;pica que constituy&#243; el mapa de los CDA medios&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">RMD se realiz&#243; en 23 pacientes con TCE grave ingresados en UCI entre 2001 y 2004&#46; Se seleccionaron para su an&#225;lisis 26 regiones de inter&#233;s y se recogi&#243; el CDA en cada una de ellas&#46; Se observ&#243; un incremento en la difusi&#243;n en las lesiones ocupantes de espacio no evacuadas respecto a otros tipos de lesi&#243;n y a valores normales&#46; El pron&#243;stico&#44; seg&#250;n la escala de resultados de Glasgow&#44; fue peor en los pacientes con valores de CDA m&#225;s bajos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Los CDA medios fueron mayores que los valores normales y mayores en las contusiones que en otros tipos de lesi&#243;n&#44; como expresi&#243;n de edema extracelular&#46; Los CDA estaban disminuidos en pacientes con mal pron&#243;stico sugiriendo una asociaci&#243;n entre isquemia y pron&#243;stico&#46;</p>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Prieto-Valderrey F&#44; Mu&#241;iz-Montes JR&#44; L&#243;pez-Garc&#237;a JA&#44; Villegas-del Ojo J&#44; M&#225;laga-Gil J&#44; Galv&#225;n-Garc&#237;a R&#46; Utilidad de la resonancia magn&#233;tica potenciada en difusi&#243;n en pacientes con lesiones focales por traumatismo craneoencef&#225;lico grave&#46; Med Intensiva&#46; 2013&#59;37&#58;375&#8211;382&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patient outcome according to the ADC findings&#44; globally and corresponding to the three measurement timepoints&#46;</p>"
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      1 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">APACHE&#58; acute physiology and chronic health evaluation&#59; SD&#58; standard deviation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Epidemiological data&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#47;&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">APACHE II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Traffic accident&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glasgow coma score 3&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glasgow coma score 6&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#37;&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Types of injuries&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Initial CAT&#58; injury type <span class="elsevierStyleSmallCaps">ii</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial CAT&#58; injury type <span class="elsevierStyleSmallCaps">iii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial CAT&#58; injury type <span class="elsevierStyleSmallCaps">iv</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial CAT&#58; injury type <span class="elsevierStyleSmallCaps">v</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial CAT&#58; injury type <span class="elsevierStyleSmallCaps">vi</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
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            1 => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Type <span class="elsevierStyleSmallCaps">i</span> diffuse lesion &#40;no visible alterations&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No intracranial alterations visible in CAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type <span class="elsevierStyleSmallCaps">ii</span> diffuse lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Permeable basal cisterns&#46; Midline deviation is &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46; No high-density lesions or mixed-density lesions larger than 25<span class="elsevierStyleHsp" style=""></span>ml&#46; Possible bone fragments or foreign bodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type <span class="elsevierStyleSmallCaps">iii</span> diffuse lesion &#40;swelling&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compressed or absent cisterns&#46; Midline deviation is &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46; No high-density lesions or mixed-density lesions larger than 25<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type <span class="elsevierStyleSmallCaps">iv</span> diffuse lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Midline deviation is &#62;5<span class="elsevierStyleHsp" style=""></span>mm&#46; No high-density lesions or mixed-density lesions larger than 25<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Evacuated mass-type lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Any surgically evacuated lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Non-evacuated mass-type lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High-density lesions or mixed-density lesions larger than 25<span class="elsevierStyleHsp" style=""></span>ml&#44; not surgically evacuated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Marshall classification of injuries in the Initial CAT scan&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;18</span></a></p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Types of injuries according to the Marshall classification&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Glasgow outcome score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Discharge from ICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vegetative state&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Poor prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minimal or no disability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Good prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Glasgow outcome score&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of injury&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">ADC<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Normal mean ADC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">957&#46;80<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>194&#46;88<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Space-occupying lesions</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">985&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>197&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">890<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40 &#40;780&#8211;1090&#41; in the cortical gray matter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Untreated hemispheric hematoma or contusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1029&#46;91<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>127&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Surgically evacuated hemispheric hematoma or contusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">851&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>322&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Unilateral diffuse injury</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">876<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>250&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">890<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>40 &#40;780&#8211;1090&#41; in the cortical gray matter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diffuse axonal injury or brainstem contusion</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">929&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>182&#46;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">700<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30 &#40;620&#8211;790&#41; in the white matter730<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30 &#40;670&#8211;820&#41; in the thalamus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0010"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">ADC&#58; apparent diffusion coefficient&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0015"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">ADC units&#58; mm<span class="elsevierStyleSup">2</span>&#47;s<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span>&#46; The table reports the mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Apparent diffusion coefficient&#44; global and according to type of injury&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">95&#37;CI&#58; 95&#37; confidence interval of the mean&#59; SD&#58; standard deviation&#46; Nonsignificant &#40;Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#41;&#46; ADC units&#58; mm<span class="elsevierStyleSup">2</span>&#47;s<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">&#8722;6</span>&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GOS 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">ADC&#58; mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD &#40;95&#37;CI&#41;</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46; lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Poor outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Good outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">All injuries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">901&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>231&#46;9 &#40;753&#46;9&#8211;1048&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1006&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>148&#46;5 &#40;920&#46;4&#8211;1&#46;091&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diffuse axonal injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">916&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>191&#46;4 &#40;441&#46;0&#8211;1392&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">939&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>204&#46;9 &#40;613&#46;5&#8211;1&#46;265&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemispheric injuries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">896&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>254&#46;2 &#40;700&#46;7&#8211;1091&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1032&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>122&#46;9 &#40;944&#46;8&#8211;1&#46;120&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Mean ADC value in relation to patient outcome&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author&#47;year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Model of brain injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Experimental protocol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hanstock &#40;1994&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Percussion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 rats&#58; 9 in the trauma group&#44; 3 in the unilateral carotid ligation group&#44; and 6 controls&#46;The images were obtained 1&#44; 2 and 4<span class="elsevierStyleHsp" style=""></span>h after ischemia or trauma&#44; and the ADC values were calculated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A significant increase in ADC was observed in the damaged cortical gray matter&#44; 60<span class="elsevierStyleHsp" style=""></span>min after trauma&#46; In rats with ischemia&#44; ADC was significantly decreased at this timepoint&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alsop &#40;1996&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Percussion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 rats&#58; 6 in the trauma group and 4 controlsDWMR after injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The ADC values decreased in the first 45<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ito &#40;1996&#41;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Impact-acceleration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 rats in 4 groups&#58; control&#44; trauma alone&#44; hypoxia and hypotension&#44; and trauma with hypoxia and hypotension &#40;THH&#41;DWMR at intervals of 1<span class="elsevierStyleHsp" style=""></span>h after injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ADC in the THH group decreased quickly to a minimum 3<span class="elsevierStyleHsp" style=""></span>h after injury&#46; In trauma lone&#44; ADC did not decrease significantly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Barzo 1997<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Impact-acceleration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 rats&#58; 30 in the trauma group and 6 controlsADC and brain water content were measured immediately after injury and on days 1&#44; 3&#44; 7&#44; 14&#44; using spin-echo or SVS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> diffusion-weighted imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ADC increased in the first hour and then decreased&#44; reaching a minimum on day 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Barzo &#40;1997&#41;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Impact-acceleration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 rats &#40;42 trauma and 8 controls&#41;&#46; ADC and brain water content were measured immediately after injury and on days 1&#44; 3&#44; 7&#44; 14&#44; using spin-echo or SVS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> diffusion-weighted imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ADC increased in the first hour and then decreased&#44; reaching a minimum on day 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beaumont &#40;2000&#41;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Impact-acceleration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44 rats&#58; Group 1&#59; trauma with hypoxia and hypotension&#46; Group 2&#59; trauma aloneEffect of the addition of dopamineMeasurement of ADC at baseline and after 4<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dopamine worsened swelling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Portella &#40;2000&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Impact-acceleration<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>secondary injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Groups of rats&#58; controls&#44; moderate trauma with&#47;without hypoxia and hypotension&#44; severe trauma with&#47;without hypoxia and hypotension&#44; hypoxia&#44; and hypotension aloneSpin-echo or SVS<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> diffusion-weighted imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased cortical water content was observed 4<span class="elsevierStyleHsp" style=""></span>h after injury&#44; inversely related to the change in ADC Secondary injuries act synergically with trauma&#44; increasing intracellular water&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Van Putten &#40;2005&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Percussion<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>secondary injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 groups&#58; controls&#44; hypoxia alone&#44; trauma alone&#44; and hypoxia and traumaADC mapping 2&#44; 4&#44; 24<span class="elsevierStyleHsp" style=""></span>h and 1 week after injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Early decrease in ADC&#44; followed by an increase after one week&#46; No changes related to hypoxia were observed&#46; Good correlation to histopathological changes&nbsp;\t\t\t\t\t\t\n
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