Restricted and anisotropic displacement of water in healthy cat brain and in stroke studied by NMR diffusion imaging

Water Diffusion in the Live Human Brain is Gaussian at the Mesoscale

Imaging the live human brain at the mesoscopic scale is a desideratum in basic and clinical neurosciences. Despite the promise of diffusion MRI, the lack of an accurate model relating the measured signal and the associated microstructure has hampered its success. The widely used diffusion tensor MRI (DTI) model assumes an anisotropic Gaussian diffusion process in each voxel, but lacks the ability to capture intravoxel heterogeneity. This study explores the extension of the DTI model to mesoscopic length scales by use of the diffusion tensor distribution (DTD) model, which assumes a Gaussian diffusion process in each subvoxel. DTD MRI has shown promise in addressing some limitations of DTI, particularly in distinguishing among different types of brain cancers and elucidating multiple fiber populations within a voxel. However, its validity in live brain tissue has never been established. Here, multiple diffusion-encoded (MDE) data were acquired in the living human brain using a 3 Tesla MRI scanner with large diffusion weighting factors. Two different diffusion times (Δ = 37, 74 ms) were employed, with other scanning parameters fixed to assess signal decay differences. In vivo diffusion-weighted signals in gray and white matter were nearly identical at the two diffusion times. Fitting the signals to the DTD model yielded indistinguishable results, except in the cerebrospinal fluid (CSF)-filled voxels likely due to pulsatile flow. Overall, the study supports the time invariance of water diffusion at the mesoscopic scale in live brain parenchyma, extending the validity of the anisotropic Gaussian diffusion model in clinical brain imaging.

Large animal models of stroke and traumatic brain injury as translational tools

Acute central nervous system injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide. Studies in animal models have greatly enhanced our understanding of the complex pathophysiology that underlies TBI and stroke and enabled the preclinical screening of over 1,000 novel therapeutic agents. Despite this, the translation of novel therapeutics from experimental models to clinical therapies has been extremely poor. One potential explanation for this poor clinical translation is the choice of experimental model, given that the majority of preclinical TBI and ischemic stroke studies have been conducted in small animals, such as rodents, which have small lissencephalic brains. However, the use of large animal species such as nonhuman primates, sheep, and pigs, which have large gyrencephalic human-like brains, may provide an avenue to improve clinical translation due to similarities in neuroanatomical structure when compared with widely adopted rodent models. This purpose of this review is to provide an overview of large animal models of TBI and ischemic stroke, including the surgical considerations, key benefits, and limitations of each approach.

Stroke onset time estimation from multispectral quantitative magnetic resonance imaging in a rat model of focal permanent cerebral ischemia

Background

Quantitative T2 relaxation magnetic resonance imaging allows estimation of stroke onset time.

Aims

We aimed to examine the accuracy of quantitative T1 and quantitative T2 relaxation times alone and in combination to provide estimates of stroke onset time in a rat model of permanent focal cerebral ischemia and map the spatial distribution of elevated quantitative T1 and quantitative T2 to assess tissue status.

Methods

Permanent middle cerebral artery occlusion was induced in Wistar rats. Animals were scanned at 9.4T for quantitative T1, quantitative T2, and Trace of Diffusion Tensor (Dav) up to 4 h post-middle cerebral artery occlusion. Time courses of differentials of quantitative T1 and quantitative T2 in ischemic and non-ischemic contralateral brain tissue (ΔT1, ΔT2) and volumes of tissue with elevated T1 and T2 relaxation times ( f1, f2) were determined. TTC staining was used to highlight permanent ischemic damage.

Results

ΔT1, ΔT2, f1, f2, and the volume of tissue with both elevated quantitative T1 and quantitative T2 (VOverlap) increased with time post-middle cerebral artery occlusion allowing stroke onset time to be estimated. VOverlap provided the most accurate estimate with an uncertainty of ±25 min. At all times-points regions with elevated relaxation times were smaller than areas with Dav defined ischemia.

Conclusions

Stroke onset time can be determined by quantitative T1 and quantitative T2 relaxation times and tissue volumes. Combining quantitative T1 and quantitative T2 provides the most accurate estimate and potentially identifies irreversibly damaged brain tissue.

Oscillating gradient diffusion MRI reveals unique microstructural information in normal and hypoxia-ischemia injured mouse brains

PURPOSE

We investigated whether oscillating gradient diffusion MRI (dMRI) can provide information on brain microstructural changes after formaldehyde fixation and after hypoxic-ischemic (HI) injury beyond that provided by conventional dMRI.

METHODS

Pulsed gradient spin echo (PGSE) and oscillating gradient spin echo (OGSE) dMRI of the adult mouse brain was performed in vivo (50-200 Hz, b = 600 mm(2)/s), and a similar protocol was applied to neonatal mouse brains at 24 h after unilateral hypoxia-ischemia. Animals were perfusion fixed with 4% paraformaldehyde for ex vivo dMRI and histology.

RESULTS

Apparent diffusion coefficients (ADCs) measured in the live adult mouse brain presented tissue-dependent frequency-dependence. In vivo OGSE-ADC maps at high oscillating frequencies (>100 Hz) showed clear contrast between the molecular layer and granule cell layer in the adult mouse cerebellum. Formaldehyde fixation significantly altered the temporal diffusion spectra in several brain regions. In neonatal mouse brains with HI injury, in vivo ADC measurements from edema regions showed diminished edema contrasts at 200 Hz compared with the PGSE results. Histology showed severe tissue swelling and necrosis in the edema regions.

CONCLUSION

The results demonstrate the unique ability of OGSE-dMRI in delineating tissue microstructures at different spatial scales.

Multiparametric magnetic resonance imaging of acute experimental brain ischaemia

Ischaemia is a condition in which blood flow either drops to zero or proceeds at severely decreased levels that cannot supply sufficient oxidizable substrates to maintain energy metabolism in vivo. Brain, a highly oxidative organ, is particularly susceptible to ischaemia. Ischaemia leads to loss of consciousness in seconds and, if prolonged, permanent tissue damage is inevitable. Ischaemia primarily results in a collapse of cerebral energy state, followed by a series of subtle changes in anaerobic metabolism, ion and water homeostasis that eventually initiate destructive internal and external processes in brain tissue. (31)P and (1)H NMR spectroscopy were initially used to evaluate anaerobic metabolism in brain. However, since the early 1990s (1)H Magnetic Resonance Imaging (MRI), exploiting the nuclear magnetism of tissue water, has become the key method for assessment of ischaemic brain tissue. This article summarises multi-parametric (1)H MRI work that has exploited diffusion, relaxation and magnetisation transfer as 'contrasts' to image ischaemic brain in preclinical models for the first few hours, with a view to assessing evolution of ischaemia and tissue viability in a non-invasive manner.

Clinical MRI of acute ischemic stroke

The most important service that imaging provides to patients with ischemic stroke is to rapidly identify those patients who are most likely to benefit from immediate treatment. This group includes patients who have severe neurological symptoms due to an occlusion of a major artery, and who are candidates for recanalization using intravenous thrombolysis or intra-arterial intervention to remove the occlusion. Outcomes for these patients are determined by symptom severity, the artery that is occluded, the size of the infarct at the time of presentation, and the effect of treatment. MRI provides key physiological information through MR angiography and diffusion MRI that has been proven to be of high clinical value in identify patients who are in need of immediate treatment. Perfusion MRI provides information about the ischemic penumbra, but its clinical value is unproven. In current clinical practice, the time since stroke onset is dominant over physiologic information provided by MRI in treatment decisions. This will change only when clinical trials prove that stroke physiology as revealed by MRI is superior to time from stroke onset in promoting good clinical outcomes.

Diffusion MRI at 25: exploring brain tissue structure and function

Diffusion MRI (or dMRI) came into existence in the mid-1980s. During the last 25 years, diffusion MRI has been extraordinarily successful (with more than 300,000 entries on Google Scholar for diffusion MRI). Its main clinical domain of application has been neurological disorders, especially for the management of patients with acute stroke. It is also rapidly becoming a standard for white matter disorders, as diffusion tensor imaging (DTI) can reveal abnormalities in white matter fiber structure and provide outstanding maps of brain connectivity. The ability to visualize anatomical connections between different parts of the brain, non-invasively and on an individual basis, has emerged as a major breakthrough for neurosciences. The driving force of dMRI is to monitor microscopic, natural displacements of water molecules that occur in brain tissues as part of the physical diffusion process. Water molecules are thus used as a probe that can reveal microscopic details about tissue architecture, either normal or in a diseased state.

Diffusion MR imaging: basic principles

From their origin as simple techniques primarily used for detecting acute cerebral ischemia, diffusion MR imaging techniques have rapidly evolved into a versatile set of tools that provide the only noninvasive means of characterizing brain microstructure and connectivity, becoming a mainstay of both clinical and investigational brain MR imaging. In this article, the basic principles required for understanding diffusion MR imaging techniques are reviewed with clinical neuroradiologists in mind.

Forensic application of postmortem diffusion-weighted and diffusion tensor MR imaging of the human brain in situ

BACKGROUND AND PURPOSE

DWI and DTI of the brain have proved to be useful in many neurologic disorders and in traumatic brain injury. This prospective study aimed at the evaluation of the influence of the PMI and the cause of death on the ADC and FA for the application of DWI and DTI in forensic radiology.

MATERIALS AND METHODS

DWI and DTI of the brain were performed in situ in 20 deceased subjects with mapping of the ADC and FA. Evaluation was performed in different ROIs, and the influence of PMI and cause of death was assessed.

RESULTS

Postmortem ADC values of the brain were decreased by 49%-72% compared with healthy living controls. With increasing PMI, ADCs were significantly reduced when considering all ROIs together and, particularly, GM regions (all regions, P < .05; GM, P < .01), whereas there was no significant effect in WM. Concerning the cause of death, ADCs were significantly lower in mechanical and hypoxic brain injury than in brains from subjects having died from heart failure (traumatic brain injury, P < .005; hypoxia, P < .001). Postmortem FA was not significantly different from FA in living persons and showed no significant influence of PMI or cause of death.

CONCLUSIONS

Performing postmortem DWI and DTI of the brain in situ can provide valuable information for application in forensic medicine. ADC could be used as an indicator of PMI and could help in the assessment of the cause of death.

Neuroimaging of ischemic stroke with CT and MRI: advancing towards physiology-based diagnosis and therapy

Acute ischemic stroke is the third leading cause of death and the major cause of significant disability in adults in the USA and Europe. The number of patients who are actually treated for acute ischemic stroke is disappointingly low, despite availability of effective treatments. A major obstacle is the short window of time following stroke in which therapies are effective. Modern imaging is able to identify the ischemic penumbra, a key concept in stroke physiology. Evidence is accumulating that identification of a penumbra enhances patient management, resulting in significantly improved outcomes. Moreover, unexpectedly large proportions of patients have a substantial ischemic penumbra beyond the traditional time window and are suitable for therapy. The widespread availability of modern MRI and computed tomography systems presents new opportunities to use physiology to guide ischemic stroke therapy in individual patients. This article suggests an evidence-based alternative to contemporary acute ischemic stroke therapy.

Functional changes of apparent diffusion coefficient during visual stimulation investigated by diffusion-weighted gradient-echo fMRI

The signal source of apparent diffusion coefficient (ADC) changes induced by neural activity is not fully understood. To examine this issue, ADC-fMRI in response to a visual stimulus was obtained in isoflurane-anesthetized cats at 9.4 T. A gradient-echo technique was used for minimizing the coupling between diffusion and background field gradients, which was experimentally confirmed. In the small b-value domain (b=5 and 200 s/mm2), a functional ADC increase was detected at the middle of the visual cortex and at the cortical surface, which was caused mainly by an increase in cerebral blood volume (CBV) and inflow. With higher b-values (b=200 and 1000-1200 s/mm2), a functional ADC decrease was observed in the parenchyma and also at the cortical surface. Within the parenchyma, the ADC decrease responded faster than the BOLD signal, but was not well localized to the middle of visual cortex and almost disappeared when the intravascular signal was removed with a susceptibility contrast agent, suggesting that the decrease in ADC without contrast agent was mostly of vascular origin. At the cortical surface, an average ADC decrease of 0.5% remained after injection of the contrast agent, which may have arisen from a functional reduction of the partial volume of cerebrospinal fluid. Overall, a functional ADC change of tissue origin could not be detected under our experimental conditions.

The ‘wet mind’: water and functional neuroimaging

Functional neuroimaging has emerged as an important approach to study the brain and the mind. Surprisingly, although they are based on radically different physical approaches both positron emission tomography (PET) and magnetic resonance imaging (MRI) make brain activation imaging possible through measurements involving water molecules. So far, PET and MRI functional imaging have relied on the principle that neuronal activation and blood flow are coupled through metabolism. However, a new paradigm has emerged to look at brain activity through the observation with MRI of the molecular diffusion of water. In contrast with the former approaches diffusion MRI has the potential to reveal changes in the intrinsic water physical properties during brain activation, which could be more intimately linked to the neuronal activation mechanisms and lead to an improved spatial and temporal resolution. However, this link has yet to be fully confirmed and understood. To shed light on the possible relationship between water and brain activation, this introductory paper reviews the most recent data on the physical properties of water and on the status of water in biological tissues, and evaluates their relevance to brain diffusion MRI. The biophysical mechanisms of brain activation are then reassessed to reveal their intimacy with the physical properties of water, which may come to be regarded as the 'molecule of the mind'.

Modeling dendrite density from magnetic resonance diffusion measurements

Diffusion-weighted imaging (DWI) provides a noninvasive tool to probe tissue microstructure. We propose a simplified model of neural cytoarchitecture intended to capture the essential features important for water diffusion as measured by NMR. Two components contribute to the NMR signal in this model: (i) the dendrites and axons, which are modeled as long cylinders with two diffusion coefficients, parallel (D(L)) and perpendicular (D(T)) to the cylindrical axis, and (ii) an isotropic monoexponential diffusion component describing water diffusion within and across all other structures, i.e., in extracellular space and glia cells. The model parameters are estimated from 153 diffusion-weighted images acquired from a formalin-fixed baboon brain. A close correspondence between the data and the signal model is found, with the model parameters consistent with literature values. The model provides an estimate of dendrite density from noninvasive MR diffusion measurements, a parameter likely to be of value for understanding normal as well as abnormal brain development and function.

Characterization of cerebral tissue by MRI map ISODATA in embolic stroke in rat

ISODATA using MRI parameter-weighted images has been previously employed to characterize ischemic cell damage after stroke in rats. In an effort to increase the objectivity and to further automate the ISODATA, MRI parameter maps were now employed. Male Wistar rats were subjected to embolic stroke and received treatment via a femoral vein at 4 h post-stroke. The control rats received saline and were sacrificed at 6, 24 and 48 h after stroke, respectively. Treated rats received rtPA alone or were treated with a combination of rtPA and an antibody, 7E3 F(ab')2, against the glycoprotein receptor that binds the platelet to fibrin. These rats were sacrificed at 24, or 48, h post-stroke. T1, T2 and diffusion maps were employed for map ISODATA analysis. H&E histological analysis of coronal sections of tissue was performed and compared with map ISODATA from the corresponding sections. ISODATA signatures were highly correlated (R approximately 0.80, P < 0.0001) with the ischemic cell damage analyzed at 6, 24 and 48 h post-stroke. At 24 and 48 h after stroke, ISODATA lesion sizes were highly correlated (R > 0.97, P < 0.001) with lesion sizes measured histologically. The combination treatment of rtPA and 7E3 F(ab')2 reduced both infarction size (P < 0.002) and average signature (P < 0.03) at 48 h after stroke, compared to saline-treated animals. No significant difference was found between saline and rtPA-alone-treated rats. The map ISODATA successfully provides objective and automated quantitation of the ischemic damage in both size and severity in an embolic stroke model of rat with and without a therapeutic intervention.

Analysis of the distribution of diffusion coefficients in cat brain at 9.4 T using the inverse Laplace transformation

In this work, the usefulness of the inverse Laplace transformation (ILT) in the characterization of diffusion processes in the brain has been investigated. The method has been implemented on both phantom and in vivo cat brain data acquired at high resolution at 9.4 T. The results were compared with monoexponential and biexponential analyses of the same data. It is shown that in the case of diffusion restricted by white matter axonal tracts, the resulting diffusograms are in good agreement with the biexponential model. In gray matter, however, the non-monoexponential decay does not lead to a bimodal distribution in the ILT, even though the data can be fitted to a biexponential. This finding suggests the possibility of a distribution of diffusion coefficients rather than a discrete biexponential behavior. It is shown that this distribution is sensitive, for example, to experimental parameters such as the diffusion time. Thus, the ILT offers the possibility of implementing a unique tool for the analysis of heterogeneous diffusion, that is, the analysis of the diffusion coefficient distribution, which has the yet unexplored potential of being a valuable parameter in the characterization of tissue structure.

Early Prediction of Gross Hemorrhagic Transformation by Noncontrast Agent MRI Cluster Analysis After Embolic Stroke in Rat

Background and Purpose— Our goal was to develop magnetic resonance indices, without image contrast agent enhancement, that predict hemorrhagic transformation (HT) in a rat model of embolic stroke.

Methods— Male Wistar rats subjected to embolic stroke with (n=12) or without (n=10) the combination treatment with recombinant tissue plasminogen activator and an anti–platelet glycoprotein IIb/IIIa antibody 7E3 F(ab′) 2 initiated at 4 hours after onset of stroke were investigated using a 7-T MRI system. Radiofrequency saturation T 1 (T 1sat ) maps with magnetization transfer, apparent diffusion coefficient of water (ADC w ) maps in 3 directions, and T 2 maps were measured at 2, 24, and 48 hours after embolization. MRI data were analyzed individually and using 2D cluster plots. Histological measurements were obtained at 48 hours.

Results— Gross hemorrhage was detected at 48 hours in 7 (4 control, 3 treated) of 22 animals. The 2D cluster plot using MRI T 1sat and ADC w maps obtained at 2 hours after stroke predicted all gross HT. The location of gross hemorrhage predicted by the 2D cluster plot was within 0.75 mm of the identifying MRI cluster.

Conclusions— The 2D MRI cluster plot analysis using T 1sat and ADC w maps acquired at 2 hours after the onset of embolic stroke predicts gross HT.

Role of immediate postictal diffusion-weighted MRI in localizing epileptogenic foci of mesial temporal lobe epilepsy and non-lesional neocortical epilepsy

OBJECTIVE

To determine whether meaningful changes in signal intensity or in the apparent diffusion coefficient of water (ADC) in the ictal onset zone can be detected through immediate postictal and interictal diffusion-weighted magnetic resonance imaging (DWMRI) in patients with localization-related epilepsy.

METHOD

In randomly selected 10 medial and lateral temporal lobe epilepsy (TLE) and four extratemporal epilepsy patients, DWMRI was performed immediately after a seizure and during the interictal period. All 14 patients were non-lesional except for hippocampal sclerosis detected on MRI. The mean time interval from seizure onset to postictal DWMRI was 81 min. Regions of interest (ROI) were selected in both the cortex, which was believed to be the ictal onset zone, and the corresponding anatomical region of the contralateral hemisphere in the postictal and interictal DWMRI. The mean ADC measured from all ROIs was compared. Ictal onset zones were determined by ictal electroencephalography (EEG) and seizure semiology.

RESULTS

On visual inspection of postictal and interictal DWMRI, signal changes in the ictal onset zone could be identified in only one patient with medial TLE. The mean ADC values from the ictal onset zones were not significantly different from those of the corresponding contralateral regions of the cortices in both postictal and interictal DWMRI. However, the postictal ADC values of the epileptogenic foci of neocortical epilepsy or neocortical temporal portion of TLE without hippocampal sclerosis were decreased compared with interictal ones in whom both interictal and postictal DWMRIs were obtained (P = 0.028).

CONCLUSION

Our results demonstrate that water diffusion can change even after a single seizure in non-lesional neocortical epilepsy.

Multiparametric ISODATA analysis of embolic stroke and rt-PA intervention in rat

To increase the sensitivity of MRI parameters to detect tissue damage of ischemic stroke, an unsupervised analysis method, Iterative Self-Organizing Data Analysis Technique Algorithm (ISODATA), was applied to analyze the temporal evolution of ischemic damage in a focal embolic cerebral ischemia model in rat with and without recombinant tissue plasminogen activator (rt-PA) treatment. Male Wistar rats subjected to embolic stroke were investigated using a 7-T MRI system. Rats were randomized into control (n=9) and treated (n=9) groups. The treated rats received rt-PA via a femoral vein at 4 h after onset of embolic ischemia. ISODATA analysis employed parametric maps or weighted images (T1, T2, and diffusion). ISODATA results with parametric maps are superior to ISODATA with weighted images, and both of them were highly correlated with the infarction size measured from the corresponding histological section. At 24 h after embolic stroke, the average map ISODATA lesion sizes were 37.7+/-7.0 and 39.2+/-5.6 mm2 for the treated and the control group, respectively. Average histological infarction areas were 37.9+/-7.4 mm2 for treated rats and 39.4+/-6.1 mm2 for controls. The R2 values of the linear correlation between map ISODATA and histological data were 0.98 and 0.96 for treated and control rats, respectively. Both histological and map ISODATA data suggest that there is no significant difference in infarction area between non-treated and rt-PA-treated rats when treatment was administered 4 h after the onset of embolic stroke. The ISODATA lesion size analysis was also sensitive to changes of lesion size during acute and subacute stages of stroke. Our data demonstrate that the multiparameter map ISODATA approach provides a more sensitive quantitation of the ischemic lesion at all time points than image ISODATA and single MRI parametric analysis using T1, T2 or ADCw.

Oscillating gradient measurements of water diffusion in normal and globally ischemic rat brain

Oscillating gradients were used to probe the diffusion-time/frequency dependence of water diffusion in the gray matter of normal and globally ischemic rat brain. In terms of a conventional definition of diffusion time, the oscillating gradient measurements provided the apparent diffusion coefficient (ADC) of water with diffusion times between 9.75 ms and 375 micros, an order of magnitude shorter than previously studied in vivo. Over this range, ADCs increased as much as 24% in vivo and 50% postmortem, depending on the nature of the oscillating gradient waveform used. Novel waveforms were employed to sample narrow frequency bands of the so-called diffusion spectrum. This spectral description of ADC includes the effects of restriction and/or flow, and is independent of experimental parameters, such as diffusion time. The results in rat brain were found to be consistent with restricted diffusion and the known micro-anatomy of gray matter. Differences between normal and postmortem data were consistent with an increase in water restriction and/or a decrease in flow, and tentatively suggest that physical changes following the onset of ischemia occur on a scale of about 2 microm, similar to a typical cellular dimension in gray matter.

The basis of anisotropic water diffusion in the nervous system - a technical review

Anisotropic water diffusion in neural fibres such as nerve, white matter in spinal cord, or white matter in brain forms the basis for the utilization of diffusion tensor imaging (DTI) to track fibre pathways. The fact that water diffusion is sensitive to the underlying tissue microstructure provides a unique method of assessing the orientation and integrity of these neural fibres, which may be useful in assessing a number of neurological disorders. The purpose of this review is to characterize the relationship of nuclear magnetic resonance measurements of water diffusion and its anisotropy (i.e. directional dependence) with the underlying microstructure of neural fibres. The emphasis of the review will be on model neurological systems both in vitro and in vivo. A systematic discussion of the possible sources of anisotropy and their evaluation will be presented followed by an overview of various studies of restricted diffusion and compartmentation as they relate to anisotropy. Pertinent pathological models, developmental studies and theoretical analyses provide further insight into the basis of anisotropic diffusion and its potential utility in the nervous system.

Endovascular administration after intravenous infusion of thrombolytic agents for the treatment of patients with acute ischemic strokes

OBJECTIVE

To determine the feasibility of combined intravenous and intra-arterial thrombolytic therapy for acute ischemic strokes and to evaluate its associated risks, using magnetic resonance imaging as a triage tool. Intravenous treatment followed by intra-arterial infusion may increase the rate of recanalization and lead to better clinical results, with reduced frequency of intracranial hemorrhage.

METHODS

Our Brain Attack Team evaluated patients who presented within 3 hours after symptom onset. Patients who did not demonstrate improvement and exhibited no evidence of intracranial hemorrhage on head computed tomographic scans were treated with intravenously administered recombinant tissue plasminogen activator (0.6 mg/kg) and underwent emergency magnetic resonance imaging of the head. T2-weighted turbo-gradient and spin echo and echo-planar diffusion- and perfusion-weighted imaging scans were obtained. Patients with evidence of imaging abnormalities indicating acute cortical infarction underwent cerebral angiography. After determination of vessel occlusion, intra-arterially administered urokinase (up to 750,000 units) or intra-arterially administered recombinant tissue plasminogen activator (maximal dose, 0.3 mg/kg) was used to achieve recanalization.

RESULTS

We treated 45 patients with this protocol. The mean age was 67 +/- 13 years, and 58% of the patients were women. There was a significant improvement in National Institutes of Health Stroke Scale scores after treatment. There was good correlation between abnormal perfusion-weighted imaging findings and cerebral angiographic findings (complete vessel occlusion). The incidence of symptomatic intracranial hemorrhage was 4.4% in this cohort. Seven patients died in the hospital, and the majority of survivors (77%) experienced good outcomes (Barthel index of >or=95) 3 months after treatment.

CONCLUSION

Our data demonstrate that this protocol is feasible and that combined intravenous and intra-arterial thrombolysis to treat acute ischemic strokes is sufficiently safe to warrant further evaluation.

Diffusion MR imaging of acute ischemic stroke

Diffusion MR imaging provides unique information about the physiologic state of ischemic tissue. It is highly sensitive and specific in the detection of acute and hyperacute ischemic stroke and has greatly improved the diagnosis and treatment of acute stroke. The DWI abnormality provides information about clinical outcome and final infarct size. Diffusion combined with perfusion MR imaging provides information about the operational ischemic penumbra and final infarct size. Diffusion MR imaging seems to be promising in the evaluation of candidates for thrombolysis.

Imaging transgenic animals

Transgenic and eugenic animals as small as 30 g can be studied non-invasively by radionuclides with resolutions of 1-2 mm, by MRI with resolution of 100 microns and by light fluorescence and bioluminescence with high sensitivities. The technologies of radionuclide emission, magnetic resonance imaging, magnetic resonance spectroscopy, optical tomography, optical fluorescence and optical bioluminescence are currently being applied to small-animal studies. These technologies and examples of their applications are reviewed in this chapter.

Applications of DWI in clinical neurology

Echo planar diffusion-weighted imaging (EP DWI) provides information about the physiologic state of the brain that is not available on conventional magnetic resonance (MR) images. Specifically, it provides signal proportional to the molecular diffusion of water molecules. It has proven highly sensitive in the detection of acute infarction and it is reliable in differentiating acute stroke from other diseases that mimic acute stroke clinically and on conventional MR images. With perfusion imaging, diffusion-weighted imaging is useful in predicting final infarct size and patient outcome. Diffusion MR is also becoming increasingly useful in the evaluation of a wide variety of other disease processes including neoplasms, intracranial infections and traumatic brain injury. Because acute stroke is common in the differential diagnosis of the majority of patients who present with acute neurologic deficits, diffusion-weighted imaging has become an essential sequence.

Diffusion tensor imaging: concepts and applications

The success of diffusion magnetic resonance imaging (MRI) is deeply rooted in the powerful concept that during their random, diffusion-driven displacements molecules probe tissue structure at a microscopic scale well beyond the usual image resolution. As diffusion is truly a three-dimensional process, molecular mobility in tissues may be anisotropic, as in brain white matter. With diffusion tensor imaging (DTI), diffusion anisotropy effects can be fully extracted, characterized, and exploited, providing even more exquisite details on tissue microstructure. The most advanced application is certainly that of fiber tracking in the brain, which, in combination with functional MRI, might open a window on the important issue of connectivity. DTI has also been used to demonstrate subtle abnormalities in a variety of diseases (including stroke, multiple sclerosis, dyslexia, and schizophrenia) and is currently becoming part of many routine clinical protocols. The aim of this article is to review the concepts behind DTI and to present potential applications.

Condition number as a measure of noise performance of diffusion tensor data acquisition schemes with MRI

Diffusion tensor mapping with MRI can noninvasively track neural connectivity and has great potential for neural scientific research and clinical applications. For each diffusion tensor imaging (DTI) data acquisition scheme, the diffusion tensor is related to the measured apparent diffusion coefficients (ADC) by a transformation matrix. With theoretical analysis we demonstrate that the noise performance of a DTI scheme is dependent on the condition number of the transformation matrix. To test the theoretical framework, we compared the noise performances of different DTI schemes using Monte-Carlo computer simulations and experimental DTI measurements. Both the simulation and the experimental results confirmed that the noise performances of different DTI schemes are significantly correlated with the condition number of the associated transformation matrices. We therefore applied numerical algorithms to optimize a DTI scheme by minimizing the condition number, hence improving the robustness to experimental noise. In the determination of anisotropic diffusion tensors with different orientations, MRI data acquisitions using a single optimum b value based on the mean diffusivity can produce ADC maps with regional differences in noise level. This will give rise to rotational variances of eigenvalues and anisotropy when diffusion tensor mapping is performed using a DTI scheme with a limited number of diffusion-weighting gradient directions. To reduce this type of artifact, a DTI scheme with not only a small condition number but also a large number of evenly distributed diffusion-weighting gradients in 3D is preferable.

Diffusion-weighted MR imaging of the brain

Diffusion-weighted magnetic resonance (MR) imaging provides image contrast that is different from that provided by conventional MR techniques. It is particularly sensitive for detection of acute ischemic stroke and differentiation of acute stroke from other processes that manifest with sudden neurologic deficits. Diffusion-weighted MR imaging also provides adjunctive information for other cerebral diseases including neoplasms, intracranial infections, traumatic brain injury, and demyelinating processes. Because stroke is common and in the differential diagnosis of most acute neurologic events, diffusion-weighted MR imaging should be considered an essential sequence, and its use in most brain MR studies is recommended.

The measurement of diffusion and perfusion in biological systems using magnetic resonance imaging

The aim of this review is to describe two recent developments in the use of magnetic resonance imaging (MRI) in the study of biological systems: diffusion and perfusion MRI. Diffusion MRI measures the molecular mobility of water in tissue, while perfusion MRI measures the rate at which blood is delivered to tissue. Therefore, both these techniques measure quantities which have direct physiological relevance. It is shown that diffusion in biological systems is a complex phenomenon, influenced directly by tissue microstructure, and that its measurement can provide a large amount of information about the organization of this structure in normal and diseased tissue. Perfusion reflects the delivery of essential nutrients to tissue, and so is directly related to its status. The concepts behind the techniques are explained, and the theoretical models that are used to convert MRI data to quantitative physical parameters are outlined. Examples of current applications of diffusion and perfusion MRI are given. In particular, the use of the techniques to study the pathophysiology of cerebral ischaemia/stroke is described. It is hoped that the biophysical insights provided by this approach will help to define the mechanisms of cell damage and allow evaluation of therapies aimed at reducing this damage.

Diffusion-weighted imaging identifies a subset of lacunar infarction associated with embolic source

BACKGROUND AND PURPOSE

Small infarcts in the territory of penetrator arteries were described as causing a number of distinct clinical syndromes. The vascular pathophysiology underlying such infarcts is difficult to ascertain without careful pathological study. However, the occurrence of multiple, small infarcts, linked closely in time but dispersed widely in the brain, raises the possibility of an embolic mechanism. The current study determines the frequency and clinical characteristics of patients with well-defined lacunar syndromes and the diffusion-weighted imaging (DWI) evidence of multiple acute lesions.

METHODS

Sixty-two consecutive patients who presented to the emergency room with a clinically well-defined lacunar syndrome were studied by DWI within the first 3 days of admission.

RESULTS

DWI showed multiple regions of increased signal intensity in 10 patients (16%). A hemispheric or brain stem lesion in a penetrator territory that accounted for the clinical syndrome ("index lesion") was found in all. DWI-hyperintense lesions other than the index lesion ("subsidiary infarctions") were punctate and lay within leptomeningeal artery territories in the majority. As opposed to patients with a single lacunar infarction, patients with a subsidiary infarction more frequently (P<0.05) harbored an identifiable cause of stroke.

CONCLUSIONS

Almost 1 of every 6 patients presenting with a classic lacunar syndrome has multiple infarctions demonstrated on DWI. This DWI finding usually indicates an identifiable cause of stroke and therefore may influence clinical decisions regarding the extent of etiologic investigations and treatment for secondary prevention.

Quantitative diffusion-tensor anisotropy brain MR imaging: normative human data and anatomic analysis

PURPOSE

To obtain normative human cerebral data and evaluate the anatomic information in quantitative diffusion anisotropy magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Quantitative diffusion anisotropy MR images were obtained in 13 healthy adults by using single-shot echo-planar MR imaging and a combination of tetrahedral and orthogonal gradient encoding (whole-brain coverage in about 1 minute). White matter (WM) anatomy was assessed at visual inspection, and values were measured in various brain regions. Different anisotropy measures, including total anisotropy (A sigma), were compared on the basis of information content, rotational invariance, and susceptibility to noise. Partial volume and noise effects were simulated.

RESULTS

Anisotropy MR images depicted WM features not typically seen on conventional MR images (e.g., external capsule, thalamic substructures, basal ganglia, occipital WM, thickness of the internal capsule). Statistically significant anisotropy differences occurred across brain regions, which were reproducible within and across subjects. A sigma was highest in commissural WM and progressively lower in projection and association WM. This order paralleled that of known resistance to spread of vasogenic edema, which suggested that anisotropy may be sensitive to WM histologic structure. Gray matter (GM) A sigma data were consistent with zero anisotropy, and partial volume WM-GM effects were approximately linear. A sigma image quality could be effectively improved by means of averaging.

CONCLUSION

Quantitative diffusion anisotropy images can be obtained rapidly and demonstrate subtle WM anatomy. Different histologic types of WM have significant and reproducible anisotropy differences.

Human acute cerebral ischemia: detection of changes in water diffusion anisotropy by using MR imaging

PURPOSE

To (a) determine the optimal choice of a scalar metric of anisotropy and (b) determine by means of magnetic resonance imaging if changes in diffusion anisotropy occurred in acute human ischemic stroke.

MATERIALS AND METHODS

The full diffusion tensor over the entire brain was measured. To optimize the choice of a scalar anisotropy metric, the performances of scalar indices in simulated models and in a healthy volunteer were analyzed. The anisotropy, trace apparent diffusion coefficient (ADC), and eigenvalues of the diffusion tensor in lesions and contralateral normal brain were compared in 50 patients with stroke.

RESULTS

Changes in anisotropy in patients were quantified by using fractional anisotropy because it provided the best performance in terms of contrast-to-noise ratio as a function of signal-to-noise ratio in simulations. The anisotropy of ischemic white matter decreased (P = .01). Changes in anisotropy in ischemic gray matter were not significant (P = .63). The trace ADC decreased for ischemic gray matter and white matter (P < .001). The first and second eigenvalues decreased in both ischemic gray and ischemic white matter (P < .001). The third eigenvalue decreased in ischemic gray (P = .001) and white matter (P = .03).

CONCLUSION

Gray matter is mildly anisotropic in normal and early ischemic states. However, early white matter ischemia is associated with not only changes in trace ADC values but also significant changes in the anisotropy, or shape, of the water self-diffusion tensor.

Acute cerebral infarction: quantification of spin-density and T2 shine-through phenomena on diffusion-weighted MR images

PURPOSE

To quantify the relative contributions of spin density and T2 effects ("shine through") on diffusion-weighted (DW) magnetic resonance (MR) images of acute and subacute cerebral infarction.

MATERIALS AND METHODS

In 30 patients, 1.5-T imaging was performed within the first 7 days after onset of cerebral infarction. Estimates of T2, spin density, and apparent diffusion coefficient (ADC) in the region of stroke and contralateral normal brain were computed by means of standard regression techniques after quadruple-echo conventional MR imaging and single-shot echo-planar DW imaging with a maximum b value of 1,000 sec/mm2. Expected signal intensity (S) enhancement ratios resulting from independent changes in T2, spin density, and ADC were then calculated for the DW sequence.

RESULTS

The overall SI of cerebral infarction on DW images was significantly higher than that of normal brain throughout the 1st week after stroke (mean relative SI enhancement ratio, 2.29; P < .001). During the first 2 days after stroke, decreased ADC within the stroke region made the dominant contribution to increased SI on DW images. By day 3, increased T2 values in the stroke region became equally important, and, from days 3-7, the contribution to SI from T2 effects became dominant. A slight increase of spin density in the stroke region made a relatively small and constant contribution to DW SI over the 1st week.

CONCLUSION

The increased SI of subacute cerebral infarction on DW images reflects not only a shortening of ADC but a prolongation of T2 and spin-density values.

Hyperacute stroke: ultrafast MR imaging to triage patients prior to therapy

PURPOSE

To test diffusion- and perfusion-weighted MR imaging techniques within the extreme time constraints of stroke evaluation before therapy, and then, with MR imaging, stratify patients into those without ischemia, those with noncortical ischemia, and those with cortical ischemia.

MATERIALS AND METHODS

T2-weighted turbo gradient- and spin-echo images and echo-planar diffusion- and perfusion-weighted images were obtained. Trace diffusion-weighted images and time-to-peak perfusion maps were automatically postprocessed and immediately available for interpretation.

RESULTS

Forty-one patients with acute stroke symptoms underwent imaging within 6 hours of symptom onset; 35 were eligible for the therapy protocol. The mean time from entering the emergency department to beginning MR imaging was 45 minutes; the mean total MR imaging time was less than 15 minutes. Immediate image analysis directly affected individual clinical management. Four patients showed evidence of no infarct; seven, of lacunar infarct; and 24, of acute cortical infarct. Sixteen patients underwent angiography, thirteen had large-vessel occlusion, eleven were treated intraarterially, and in seven, recanalization was achieved.

CONCLUSION

Echo-planar diffusion- and perfusion-weighted MR imaging for acute stroke is feasible and applicable before therapy decisions. Ultrafast MR imaging permitted immediate triage of 35 patients with symptoms of hyperacute stroke and thus helped avoid the risks from angiography and thrombolytic agents in some or spurred the judicious use of more aggressive intervention in others.

Imaging of acute cerebral ischemia

Until recently, there was no efficacious treatment for acute cerebral ischemia. As a result, the role of neuroimaging and the radiologist was peripheral in the diagnosis and management of this disease. The demonstration of efficacy using thrombolysis has redefined this role, with the success of intervention becoming increasingly dependent on timely imaging and accurate interpretation. The potential benefits of intervention have only begun to be realized. In this State-of-the-Art review of imaging of acute stroke, the role of imaging in the current and future management of stroke is presented. The role of computed tomography is emphasized in that it is currently the most utilized technique, and its value has been demonstrated in prospective clinical trials. Magnetic resonance techniques are equally emphasized in that they have the potential to provide a single modality evaluation of tissue viability and vessel patency in an increasingly rapid evaluation.

Diffusion magnetic resonance imaging: its principle and applications

Diffusion magnetic resonance imaging (MRI) is one of the most rapidly evolving techniques in the MRI field. This method exploits the random diffusional motion of water molecules, which has intriguing properties depending on the physiological and anatomical environment of the organisms studied. We explain the principles of this emerging technique and subsequently introduce some of its present applications to neuroimaging, namely detection of ischemic stroke and reconstruction of axonal bundles and myelin fibers.

Normal diffusion-weighted MRI during stroke-like deficits

BACKGROUND

Diffusion-weighted MRI (DWI) represents a major advance in the early diagnosis of acute ischemic stroke. When abnormal in patients with stroke-like deficit, DWI usually establishes the presence and location of ischemic brain injury. However, this is not always the case.

OBJECTIVE

To investigate patients with stroke-like deficits occurring without DWI abnormalities in brain regions clinically suspected to be responsible.

METHODS

We identified 27 of 782 consecutive patients scanned when stroke-like neurologic deficits were still present and who had normal DWI in the brain region(s) clinically implicated. Based on all the clinical and radiologic data, we attempted to arrive at a pathophysiologic diagnosis in each.

RESULTS

Best final diagnosis was a stroke mimic in 37% and a cerebral ischemic event in 63%. Stroke mimics (10 patients) included migraine, seizures, functional disorder, transient global amnesia, and brain tumor. The remaining patients were considered to have had cerebral ischemic events: lacunar syndrome (7 patients; 3 with infarcts demonstrated subsequently) and hemispheric cortical syndrome (10 patients; 5 with TIA, 2 with prolonged reversible deficits, 3 with infarction on follow-up imaging). In each of the latter three patients, the regions destined to infarct showed decreased perfusion on the initial hemodynamically weighted MRI (HWI).

CONCLUSIONS

Normal DWI in patients with stroke-like deficits should stimulate a search for nonischemic cause of symptoms. However, more than one-half of such patients have an ischemic cause as the best clinical diagnosis. Small brainstem lacunar infarctions may escape detection. Concomitant HWI can identify some patients with brain ischemia that is symptomatic but not yet to the stage of causing DWI abnormality.

Orientation-independent diffusion imaging without tensor diagonalization: anisotropy definitions based on physical attributes of the diffusion ellipsoid

Diffusion tensor imaging can provide a complete description of the diffusion process in tissue. However, this description is not unique but is orientation dependent, and, to quantify properly the intrinsic orientation-independent diffusion properties of the tissue, a set of three rotationally invariant quantities is needed. Instead of using the tensor eigenvalues for this, we define a new set consisting of scaled invariants that have the proper magnitude of actual diffusion constants and that are directly related to the physical attributes of the diffusion ellipsoid, namely, its average radius, surface, and volume. Using these three physical invariants, a new family of anisotropy measures is defined that are normalized between zero (isotropic) and one (completely anisotropic). Because rotational invariants are used, this approach does not require tensor diagonalization and eigenvalue determination and is therefore not susceptible to potential artifacts induced during these number manipulations. The relationship between the new anisotropy definitions and existing orientation-independent anisotropy indices obtained from eigenvalues is discussed, after which the new approach is evaluated for a group of healthy volunteers.

An echo-shifted gradient-echo MRI method for efficient diffusion weighting

A segmented magnetic resonance imaging (MRI) method is introduced with time-efficient diffusion weighting resulting in total imaging times similar to those of single-shot methods. The approach is based on the principles of echo shifting with a train of observations (PRESTO) MRI sequence. The time efficiency of the sequence is based on the use of diffusion gradient pulses that also serve to shift the echo train to the next TR period, resulting in TE > TR. Each diffusion gradient is therefore used twice, for dephasing one set of spins as well as rephasing a second set of spins. Diffusion weighting and acquisition are thus achieved simultaneously. The sequence is validated in vitro and in vivo on rat kidney.

Diffusional anisotropy is induced by subcellular barriers in skeletal muscle

The time- and orientational-dependence of phosphocreatine (PCr) diffusion was measured using pulsed-field gradient nuclear magnetic resonance (PFG-NMR) as a means of non-invasively probing the intracellular diffusive barriers of skeletal muscle. Red and white skeletal muscle from fish was used because fish muscle cells are very large, which facilitates the examination of diffusional barriers in the intracellular environment, and because they have regions of very homogeneous fiber type. Fish were cold-acclimated (5 degrees C) to amplify the contrast between red and white fibers. Apparent diffusion coefficients, D, were measured axially, D(axially) and radially, D(radially), in small muscle strips over a time course ranging from 12 to 700 ms. Radial diffusion was strongly time dependent in both fiber types, and D decreased with time until a steady-state value was reached at a diffusion time approximately 100 ms. Diffusion was also highly anisotropic, with D(axially) being higher than D(radially) for all time points. The time scale over which changes in D(radially) occurred indicated that the observed anisotropy was not a result of interactions with the thick and thin filament lattice of actin and myosin or restriction within the cylindrical sarcolemma, as has been previously suggested. Rather, the sarcoplasmic reticulum (SR) and mitochondria appear to be the principal intracellular structures that inhibit mobility in an orientation-dependent manner. This work is the first example of diffusional anisotropy induced by readily identifiable intracellular structures.

Multi-component apparent diffusion coefficients in human brain

The signal decay with increasing b-factor at fixed echo time from brain tissue in vivo has been measured using a line scan Stejskal-Tanner spin echo diffusion approach in eight healthy adult volunteers. The use of a 175 ms echo time and maximum gradient strengths of 10 mT/m allowed 64 b-factors to be sampled, ranging from 5 to 6000 s/ mm2, a maximum some three times larger than that typically used for diffusion imaging. The signal decay with b-factor over this extended range showed a decidedly non-exponential behavior well-suited to biexponential modeling. Statistical analyses of the fitted biexponential parameters from over 125 brain voxels (15 x 15 x 1 mm3 volume) per volunteer yielded a mean volume fraction of 0.74 which decayed with a typical apparent diffusion coefficient around 1.4 microm2/ms. The remaining fraction had an apparent diffusion coefficient of approximately 0.25 microm2/ms. Simple models which might explain the non-exponential behavior, such as intra- and extracellular water compartmentation with slow exchange, appear inadequate for a complete description. For typical diffusion imaging with b-factors below 2000 s/mm2, the standard model of monoexponential signal decay with b-factor, apparent diffusion coefficient values around 0.7 microm2/ms, and a sensitivity to diffusion gradient direction may appear appropriate. Over a more extended but readily accessible b-factor range, however, the complexity of brain signal decay with b-factor increases, offering a greater parametrization of the water diffusion process for tissue characterization.

Three-dimensional tracking of axonal projections in the brain by magnetic resonance imaging

The relationship between brain structure and complex behavior is governed by large-scale neurocognitive networks. The availability of a noninvasive technique that can visualize the neuronal projections connecting the functional centers should therefore provide new keys to the understanding of brain function. By using high-resolution three-dimensional diffusion magnetic resonance imaging and a newly designed tracking approach, we show that neuronal pathways in the rat brain can be probed in situ. The results are validated through comparison with known anatomical locations of such fibers.