Pulsed magnetization transfer contrast in gradient echo imaging: a two-pool analytic description of signal response

Creatine mapping of the brain at 3T by CEST MRI

PURPOSE

To assess the feasibility of CEST-based creatine (Cr) mapping in brain at 3T using the guanidino (Guan) proton resonance.

METHODS

Wild type and knockout mice with guanidinoacetate N-methyltransferase deficiency and low Cr and phosphocreatine (PCr) concentrations in the brain were used to assign the Cr and protein-based arginine contributions to the GuanCEST signal at 2.0 ppm. To quantify the Cr proton exchange rate, two-step Bloch-McConnell fitting was used to fit the extracted CrCEST line-shape and multi-B1 Z-spectral data. The pH response of GuanCEST was simulated to demonstrate its potential for pH mapping.

RESULTS

Brain Z-spectra of wild type and guanidinoacetate N-methyltransferase deficiency mice show a clear Guan proton peak at 2.0 ppm at 3T. The CrCEST signal contributes ∼23% to the GuanCEST signal at B1  = 0.8 μT, where a maximum CrCEST effect of 0.007 was detected. An exchange rate range of 200-300 s-1 was estimated for the Cr Guan protons. As revealed by the simulation, an elevated GuanCEST in the brain is observed when B1 is less than 0.4 μT at 3T, when intracellular pH reduces by 0.2. Conversely, the GuanCEST decreases when B1 is greater than 0.4 μT with the same pH drop.

CONCLUSIONS

CrCEST mapping is possible at 3T, which has potential for detecting intracellular pH and Cr concentration in brain.

B1 inhomogeneity-corrected T1 mapping and quantitative magnetization transfer imaging via simultaneously estimating Bloch-Siegert shift and magnetization transfer effects

PURPOSE

To introduce a method of inducing Bloch-Siegert shift and magnetization Transfer Simultaneously (BTS) and demonstrate its utilization for measuring binary spin-bath model parameters free pool spin-lattice relaxation (T 1 F $$ {T}_1^{\mathrm{F}} $$ ), macromolecular fraction (f $$ f $$ ), magnetization exchange rate (k F $$ {k}_{\mathrm{F}} $$ ) and local transmit field (B 1 + $$ {B}_1^{+} $$ ).

THEORY AND METHODS

Bloch-Siegert shift and magnetization transfer is simultaneously induced through the application of off-resonance irradiation in between excitation and acquisition of an RF-spoiled gradient-echo scheme. Applying the binary spin-bath model, an analytical signal equation is derived and verified through Bloch simulations. Monte Carlo simulations were performed to analyze the method's performance. The estimation of the binary spin-bath parameters withB 1 + $$ {B}_1^{+} $$ compensation was further investigated through experiments, both ex vivo and in vivo.

RESULTS

Comparing BTS with existing methods, simulations showed that existing methods can significantly biasT 1 $$ {T}_1 $$ estimation when not accounting for transmitB 1 $$ {B}_1 $$ heterogeneity and MT effects that are present. Phantom experiments further showed that the degree of this bias increases with increasing macromolecular proton fraction. Multi-parameter fit results from an in vivo brain study generated values in agreement with previous literature. Based on these studies, we confirmed that BTS is a robust method for estimating the binary spin-bath parameters in macromolecule-rich environments, even in the presence ofB 1 + $$ {B}_1^{+} $$ inhomogeneity.

CONCLUSION

A method of estimating Bloch-Siegert shift and magnetization transfer effect has been developed and validated. Both simulations and experiments confirmed that BTS can estimate spin-bath parameters (T 1 F $$ {T}_1^{\mathrm{F}} $$ ,f $$ f $$ ,k F $$ {k}_{\mathrm{F}} $$ ) that are free fromB 1 + $$ {B}_1^{+} $$ bias.

Microscopic theory of spin-spin and spin-lattice relaxation of bound protons in cellular and myelin membranes-A lateral diffusion model (LDM)

PURPOSE

Deciphering salient features of biological tissue cellular microstructure in health and diseases is an ultimate goal of MRI. While most MRI approaches are based on studying MR properties of tissue "free" water indirectly affected by tissue microstructure, other approaches, such as magnetization transfer (MT), directly target signals from tissue-forming macromolecules. However, despite three-decades of successful applications, relationships between MT measurements and tissue microstructure remain elusive, hampering interpretation of experimental results. The goal of this paper is to develop microscopic theory connecting the structure of cellular and myelin membranes to their MR properties.

THEORY AND METHODS

Herein we introduce a lateral diffusion model (LDM) that explains the T2 (spin-spin) and T1 (spin-lattice) MRI relaxation properties of the macromolecular-bound protons by their dipole-dipole interaction modulated by the lateral diffusion of long lipid molecules forming cellular and myelin membranes.

RESULTS

LDM predicts anisotropic T1 and T2 relaxation of membrane-bound protons. Moreover, their T2 relaxation cannot be described in terms of a standard R2  = 1/T2 relaxation rate parameter, but rather by a relaxation rate function R2 (t) that depends on time t after RF excitation, having, in the main approximation, a logarithmic behavior: R2 (t) ∼ lnt. This anisotropic non-linear relaxation leads to an absorption lineshape that is different from Super-Lorentzian traditionally used in interpreting MT experiments.

CONCLUSION

LDM-derived analytical equations connect the membrane-bound protons T1 and T2 relaxation with dynamic distances between protons in neighboring membrane-forming lipid molecules and their lateral diffusion. This sheds new light on relationships between MT parameters and microstructure of cellular and myelin membranes.

Obesity-Related Neuroinflammation: Magnetic Resonance and Microscopy Imaging of the Brain

Obesity is a major risk factor of Alzheimer’s disease and related dementias. The principal feature of dementia is a loss of neurons and brain atrophy. The mechanistic links between obesity and the neurodegenerative processes of dementias are not fully understood, but recent research suggests that obesity-related systemic inflammation and subsequent neuroinflammation may be involved. Adipose tissues release multiple proinflammatory molecules (fatty acids and cytokines) that impact blood and vessel cells, inducing low-grade systemic inflammation that can transition to tissues, including the brain. Inflammation in the brain—neuroinflammation—is one of key elements of the pathobiology of neurodegenerative disorders; it is characterized by the activation of microglia, the resident immune cells in the brain, and by the structural and functional changes of other cells forming the brain parenchyma, including neurons. Such cellular changes have been shown in animal models with direct methods, such as confocal microscopy. In humans, cellular changes are less tangible, as only indirect methods such as magnetic resonance (MR) imaging are usually used. In these studies, obesity and low-grade systemic inflammation have been associated with lower volumes of the cerebral gray matter, cortex, and hippocampus, as well as altered tissue MR properties (suggesting microstructural variations in cellular and molecular composition). How these structural variations in the human brain observed using MR imaging relate to the cellular variations in the animal brain seen with microscopy is not well understood. This review describes the current understanding of neuroinflammation in the context of obesity-induced systemic inflammation, and it highlights need for the bridge between animal microscopy and human MR imaging studies.

Learning-based optimization of acquisition schedule for magnetization transfer contrast MR fingerprinting

Magnetization transfer contrast MR fingerprinting (MTC-MRF) is a novel quantitative imaging method that simultaneously quantifies free bulk water and semisolid macromolecule parameters using pseudo-randomized scan parameters. To improve acquisition efficiency and reconstruction accuracy, the optimization of MRF sequence design has been of recent interest in the MRF field, but has been challenging due to the large number of degrees of freedom to be optimized in the sequence. Herein, we propose a framework for learning-based optimization of the acquisition schedule (LOAS), which optimizes RF saturation-encoded MRF acquisitions with a minimal number of scan parameters for tissue parameter determination. In a supervised learning framework, scan parameters were subsequently updated to minimize a predefined loss function that can directly represent tissue quantification errors. We evaluated the performance of the proposed approach with a numerical phantom and in in vivo experiments. For validation, MRF images were synthesized using the tissue parameters estimated from a fully connected neural network framework and compared with references. Our results showed that LOAS outperformed existing indirect optimization methods with regard to quantification accuracy and acquisition efficiency. The proposed LOAS method could be a powerful optimization tool in the design of MRF pulse sequences.

Magnetization transfer weighted EPI facilitates cortical depth determination in native fMRI space

The increased availability of ultra-high field scanners provides an opportunity to perform fMRI at sub-millimeter spatial scales and enables in vivo probing of laminar function in the human brain. In most previous studies, the definition of cortical layers, or depths, is based on an anatomical reference image that is collected by a different acquisition sequence and exhibits different geometric distortion compared to the functional images. Here, we propose to generate the anatomical image with the fMRI acquisition technique by incorporating magnetization transfer (MT) weighted imaging. Small flip angle binomial pulse trains are used as MT preparation, with a flexible duration (several to tens of milliseconds), which can be applied before each EPI segment without constraining the acquisition length (segment or slice number). The method's feasibility was demonstrated at 7T for coverage of either a small slab or the near-whole brain at 0.8 mm isotropic resolution. Tissue contrast was found to be similar to that obtained with a state-of-art anatomical reference based on MP2RAGE. This MT-weighted EPI image allows an automatic reconstruction of the cortical surface to support laminar analysis in native fMRI space, obviating the need for distortion correction and registration.

New insights into the dynamic development of the cerebral cortex in childhood and adolescence: Integrating macro- and microstructural MRI findings

Through dynamic transactional processes between genetic and environmental factors, childhood and adolescence involve reorganization and optimization of the cerebral cortex. The cortex and its development plays a crucial role for prototypical human cognitive abilities. At the same time, many common mental disorders appear during these critical phases of neurodevelopment. Magnetic resonance imaging (MRI) can indirectly capture several multifaceted changes of cortical macro- and microstructure, of high relevance to further our understanding of the neural foundation of cognition and mental health. Great progress has been made recently in mapping the typical development of cortical morphology. Moreover, newer less explored MRI signal intensity and specialized quantitative T2 measures have been applied to assess microstructural cortical development. We review recent findings of typical postnatal macro- and microstructural development of the cerebral cortex from early childhood to young adulthood. We cover studies of cortical volume, thickness, area, gyrification, T1-weighted (T1w) tissue contrasts such a grey/white matter contrast, T1w/T2w ratio, magnetization transfer and myelin water fraction. Finally, we integrate imaging studies with cortical gene expression findings to further our understanding of the underlying neurobiology of the developmental changes, bridging the gap between ex vivo histological- and in vivo MRI studies.

One-minute whole-brain magnetization transfer ratio imaging with intrinsic B1 -correction

PURPOSE

Magnetization transfer ratio (MTR) histograms are used widely for the assessment of diffuse pathological changes in the brain. For broad clinical application, MTR scans should not only be fast, but confounding factors should also be minimized for high reproducibility. To this end, a 1-minute whole-brain spiral MTR method with intrinsic B₁ -field correction is introduced.

METHODS

A spiral multislice spoiled gradient-echo sequence with adaptable magnetization-transfer saturation pulses (angle β) is proposed. After a low-resolution single-shot spiral readout and a dummy preparation period, high-resolution images are acquired using an interleaved spiral readout. For whole-brain MTR imaging, 50 interleaved slices with three different magnetization-transfer contrasts (β = 0°, 350°, and 550°) together with an intrinsic B₁ -field map are recorded in 58.5 seconds on a clinical 3T system. From the three contrasts, two sets of MTR images are derived and used for subsequent B₁ correction, assuming a linear dependency on β. For validation, a binary spin bath model is used.

RESULTS

For the proposed B₁ -correction scheme, numerical simulations indicate for brain tissue a decrease of about a factor of 10 for the B₁ -related bias on MTR. As a result, following B₁ correction, MTR differences in gray and white matter become markedly accentuated, and the reproducibility of MTR histograms from scan-rescan experiments is improved. Furthermore, B₁ -corrected MTR histograms show a lower variability for age-matched normal-appearing brain tissue.

CONCLUSION

From its speed and offering intrinsic B₁ correction, the proposed method shows excellent prospects for clinical studies that explore magnetization-transfer effects based on MTR histogram analysis.

Three-dimensional inhomogeneous magnetization transfer with rapid gradient-echo (3D ihMTRAGE) imaging

PURPOSE

To demonstrate the feasibility of integrating the magnetization transfer (MT) preparations required for inhomogeneous MT (ihMT) within an MPRAGE-style acquisition. Such a sequence allows for reduced power deposition and easy inclusion of other modules.

METHODS

An ihMT MPRAGE-style sequence (ihMTRAGE) was initially simulated to investigate acquisition of the 3D ihMT data sequentially, or in an interleaved manner. The ihMTRAGE sequence was implemented on a 3T clinical scanner to acquire ihMT data from the brain and spine.

RESULTS

Both simulations and in vivo data provided an ihMT signal that was significantly greater using a sequential ihMTRAGE acquisition, compared with an interleaved implementation. Comparison with a steady-state ihMT acquisition (defined as having one MT RF pulse between successive acquisition modules) demonstrated how ihMTRAGE allows for a reduction in average power deposition, or greater ihMT signal at equal average power deposition. Inclusion of a prospective motion-correction module did not significantly affect the ihMT signal obtained from regions of interest in the brain. The ihMTRAGE acquisition allowed combination with a spatial saturation module to reduce phase wrap artifacts in a cervical spinal cord acquisition.

CONCLUSIONS

Use of preparations necessary for ihMT experiments within an MPRAGE-style sequence provides a useful alternative for acquiring 3D ihMT data. Compared with our steady-state implementation, ihMTRAGE provided reduced power deposition, while allowing use of the maximum intensity from off-resonance RF pulses. The 3D ihMTRAGE acquisition allowed combination of other modules with the preparation necessary for ihMT experiments, specifically motion compensation and spatial saturation modules.

Fast bound pool fraction mapping via steady-state magnetization transfer saturation using single-shot EPI

PURPOSE

To enable clinical applications of quantitative magnetization transfer (qMT) imaging by developing a fast method to map one of its fundamental model parameters, the bound pool fraction (BPF), in the human brain.

THEORY AND METHODS

The theory of steady-state MT in the fast-exchange approximation is used to provide measurements of BPF, and bound pool transverse relaxation time ( T 2 B ). A sequence that allows sampling of the signal during steady-state MT saturation is used to perform BPF mapping with a 10-min-long fully echo planar imaging-based MRI protocol, including inversion recovery T₁ mapping and B₁ error mapping. The approach is applied in 6 healthy subjects and 1 multiple sclerosis patient, and validated against a single-slice full qMT reference acquisition.

RESULTS

BPF measurements are in agreement with literature values using off-resonance MT, with average BPF of 0.114(0.100-0.128) in white matter and 0.068(0.054-0.085) in gray matter. Median voxel-wise percentage error compared with standard single slice qMT is 4.6%. Slope and intercept of linear regression between new and reference BPF are 0.83(0.81-0.85) and 0.013(0.11-0.16). Bland-Altman plot mean bias is 0.005. In the multiple sclerosis case, the BPF is sensitive to pathological changes in lesions.

CONCLUSION

The method developed provides accurate BPF estimates and enables shorter scan time compared with currently available approaches, demonstrating the potential of bringing myelin sensitive measurement closer to the clinic.

Fibre-orientation dependent R1(=1/T1) relaxation in the brain: The role of susceptibility induced spin-lattice relaxation in the myelin water compartment

We have recently observed a dependence of the longitudinal relaxation rate, R₁, on the orientation of nerve fibres with respect to the main magnetic field. A similar dependence of R₂^∗ is long established and can be well explained by spin-dephasing in an inhomogeneous magnetic field induced by the susceptibility shift between myelin and water protons. The current study investigates if the same effect can also explain the R₁ dependence, neglecting a possible directional dependence of magnetisation transfer between solid myelin and myelin water. A molecular model of the myelin lipid bilayer was employed to simulate the susceptibility induced fields on a microscopic scale for the different nerve fibre orientations. The resulting simulated magnetic fields were used to calculate an orientation dependent relaxation offset, ΔR₁, based on both first-order perturbation theory and a simulation of the spin transition probabilities. Even though both methods yielded consistent orientation dependent relaxation offsets with a distribution that resembles the experimental data, the determined ΔR₁ values are too low to explain the reported R₁ angular dependency. Therefore, unlike R₂^∗, susceptibility induced spin flips can be excluded as a dominant source for the observed R₁ angular dependence.

CEST, ASL, and magnetization transfer contrast: How similar pulse sequences detect different phenomena

Chemical exchange saturation transfer (CEST), arterial spin labeling (ASL), and magnetization transfer contrast (MTC) methods generate different contrasts for MRI. However, they share many similarities in terms of pulse sequences and mechanistic principles. They all use RF pulse preparation schemes to label the longitudinal magnetization of certain proton pools and follow the delivery and transfer of this magnetic label to a water proton pool in a tissue region of interest, where it accumulates and can be detected using any imaging sequence. Due to the versatility of MRI, differences in spectral, spatial or motional selectivity of these schemes can be exploited to achieve pool specificity, such as for arterial water protons in ASL, protons on solute molecules in CEST, and protons on semi-solid cell structures in MTC. Timing of these sequences can be used to optimize for the rate of a particular delivery and/or exchange transfer process, for instance, between different tissue compartments (ASL) or between tissue molecules (CEST/MTC). In this review, magnetic labeling strategies for ASL and the corresponding CEST and MTC pulse sequences are compared, including continuous labeling, single-pulse labeling, and multi-pulse labeling. Insight into the similarities and differences among these techniques is important not only to comprehend the mechanisms and confounds of the contrasts they generate, but also to stimulate the development of new MRI techniques to improve these contrasts or to reduce their interference. This, in turn, should benefit many possible applications in the fields of physiological and molecular imaging and spectroscopy.

Fast quantitative MRI using controlled saturation magnetization transfer

Purpose

This study demonstrates magnetization transfer (MT) effects directly affect relaxometry measurements and develops a framework that allows single‐pool models to be valid in 2‐pool MT systems.

Methods

A theoretical framework is developed in which a 2‐pool MT system effectively behaves as a single‐pool if the RMS RF magnetic field (B1rms{\text{B}}_{1}^{{{\text{rms}}}}) is kept fixed across all measurements. A practical method for achieving controlled saturation magnetization transfer (CSMT) using multiband RF pulses is proposed. Numerical, Phantom, and in vivo validations were performed directly comparing steady state (SS) estimation approaches that under correct single‐pool assumptions would be expected to vary in precision but not accuracy.

Results

Numerical simulations predict single‐pool estimates obtained from MT model generated data are not consistent for different SS estimation methods, and a systematic underestimation of T₂ is expected. Neither effect occurs under the proposed CSMT approach. Both phantom and in vivo experiments corroborate the numerical predictions. Experimental data highlights that even when using the same relaxometry method, different estimates are obtained depending on which combination of flip angles (FAs) and TRs are used if the CSMT approach is not used. Using CSMT, stable measurements of both T₁ and T₂ are obtained. The measured T₁(T1CSMT)) depends on B1rms{\text{B}}_{1}^{{{\text{rms}}}}, which is therefore an important parameter to specify.

Conclusion

This work demonstrates that conventional single pool relaxometry, which is highly efficient for human studies, results in unreliable parameter estimates in biological tissues because of MT effects. The proposed CSMT framework is shown to allow single‐pool assumptions to be valid, enabling reliable and efficient quantitative imaging to be performed.

Visceral fat-related systemic inflammation and the adolescent brain: a mediating role of circulating glycerophosphocholines

OBJECTIVE

Life-long maintenance of brain health is important for the prevention of cognitive impairment in older age. Low-grade peripheral inflammation associated with excess visceral fat (VF) may influence brain structure and function. Here we examined (i) if this type of inflammation is associated with altered white-matter (WM) microstructure and lower cognitive functioning in adolescents, and (ii) if recently identified circulating glycerophosphocholines (GPCs) can index this type of inflammation and associated variations in WM microstructure and cognitive functioning.

SUBJECTS

We studied a community-based sample of 872 adolescents (12-18 years, 48% males) in whom we assessed VF and WM microstructure with magnetic resonance imaging, processing speed with cognitive testing, serum C-reactive protein (CRP, a common marker of peripheral inflammation) with a high-sensitivity assay, and serum levels of a panel of 64 GPCs with advanced mass spectrometry.

RESULTS

VF was associated with CRP, and CRP in turn was associated with "altered" WM microstructure and lower processing speed (all p < 0.003). Further, "altered" WM microstructure was associated with lower processing speed (p < 0.0001). Of all 64 tested GPCs, 4 were associated with both VF and CRP (at Bonferroni corrected p < 0.0004). One of them, PC16:0/2:0, was also associated with WM microstructure (p < 0.0001) and processing speed (p = 0.0003), and mediated the directed associations between VF and both WM microstructure (p < 0.0001) and processing speed (p = 0.02). As a mediator, PC16:0/2:0 explained 21% of shared variance between VF and WM microstructure, and 22% of shared variance between VF and processing speed. Similar associations were observed in an auxiliary study of 80 middle-aged adults.

CONCLUSIONS

Our results show that VF-related peripheral inflammation is associated with "altered" WM microstructure and lower cognitive functioning already in adolescents, and a specific circulating GPC may be a new molecule indexing this VF-related peripheral inflammation and its influences on brain structure and function.

Extended phase graph formalism for systems with magnetization transfer and exchange

Purpose

An extended phase graph framework (EPG‐X) for modeling systems with exchange or magnetization transfer (MT) is proposed.

Theory

EPG‐X models coupled two‐compartment systems by describing each compartment with separate phase graphs that exchange during evolution periods. There are two variants: EPG‐X(BM) for systems governed by the Bloch‐McConnell equations, and EPG‐X(MT) for the pulsed MT formalism. For the MT case, the “bound” protons have no transverse components, so their phase graph consists of only longitudinal states.

Methods

The EPG‐X model was validated against steady‐state solutions and isochromat‐based simulation of gradient‐echo sequences. Three additional test cases were investigated: (i) MT effects in multislice turbo spin‐echo; (ii) variable flip angle gradient‐echo imaging of the type used for MR fingerprinting; and (iii) water exchange in multi‐echo spin‐echo T₂ relaxometry.

Results

EPG‐X was validated successfully against isochromat based transient simulations and known steady‐state solutions. EPG‐X(MT) simulations matched in‐vivo measurements of signal attenuation in white matter in multislice turbo spin‐echo images. Magnetic resonance fingerprinting–style experiments with a bovine serum albumin (MT) phantom showed that the data were not consistent with a single‐pool model, but EPG‐X(MT) could be used to fit the data well. The EPG‐X(BM) simulations of multi‐echo spin‐echo T₂ relaxometry suggest that exchange could lead to an underestimation of the myelin‐water fraction.

Conclusions

The EPG‐X framework can be used for modeling both steady‐state and transient signal response of systems exhibiting exchange or MT. This may be particularly beneficial for relaxometry approaches that rely on characterizing transient rather than steady‐state sequences. Magn Reson Med 80:767–779, 2018. © 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Four in vivo g-ratio-weighted imaging methods: Comparability and repeatability at the group level

A recent method, denoted in vivo g-ratio-weighted imaging, has related the microscopic g-ratio, only accessible by ex vivo histology, to noninvasive MRI markers for the fiber volume fraction (FVF) and myelin volume fraction (MVF). Different MRI markers have been proposed for g-ratio weighted imaging, leaving open the question which combination of imaging markers is optimal. To address this question, the repeatability and comparability of four g-ratio methods based on different combinations of, respectively, two imaging markers for FVF (tract-fiber density, TFD, and neurite orientation dispersion and density imaging, NODDI) and two imaging markers for MVF (magnetization transfer saturation rate, MT, and, from proton density maps, macromolecular tissue volume, MTV) were tested in a scan-rescan experiment in two groups. Moreover, it was tested how the repeatability and comparability were affected by two key processing steps, namely the masking of unreliable voxels (e.g., due to partial volume effects) at the group level and the calibration value used to link MRI markers to MVF (and FVF). Our data showed that repeatability and comparability depend largely on the marker for the FVF (NODDI outperformed TFD), and that they were improved by masking. Overall, the g-ratio method based on NODDI and MT showed the highest repeatability (90%) and lowest variability between groups (3.5%). Finally, our results indicate that the calibration procedure is crucial, for example, calibration to a lower g-ratio value (g = 0.6) than the commonly used one (g = 0.7) can change not only repeatability and comparability but also the reported dependency on the FVF imaging marker. Hum Brain Mapp 39:24-41, 2018. © 2017 Wiley Periodicals, Inc.

Studying neuroanatomy using MRI

The study of neuroanatomy using imaging enables key insights into how our brains function, are shaped by genes and environment, and change with development, aging and disease. Developments in MRI acquisition, image processing and data modeling have been key to these advances. However, MRI provides an indirect measurement of the biological signals we aim to investigate. Thus, artifacts and key questions of correct interpretation can confound the readouts provided by anatomical MRI. In this review we provide an overview of the methods for measuring macro- and mesoscopic structure and for inferring microstructural properties; we also describe key artifacts and confounds that can lead to incorrect conclusions. Ultimately, we believe that, although methods need to improve and caution is required in interpretation, structural MRI continues to have great promise in furthering our understanding of how the brain works.

Magnetization Transfer Contrast and Chemical Exchange Saturation Transfer MRI. Features and analysis of the field-dependent saturation spectrum

Magnetization Transfer Contrast (MTC) and Chemical Exchange Saturation Transfer (CEST) experiments measure the transfer of magnetization from molecular protons to the solvent water protons, an effect that becomes apparent as an MRI signal loss ("saturation"). This allows molecular information to be accessed with the enhanced sensitivity of MRI. In analogy to Magnetic Resonance Spectroscopy (MRS), these saturation data are presented as a function of the chemical shift of participating proton groups, e.g. OH, NH, NH₂, which is called a Z-spectrum. In tissue, these Z-spectra contain the convolution of multiple saturation transfer effects, including nuclear Overhauser enhancements (NOEs) and chemical exchange contributions from protons in semi-solid and mobile macromolecules or tissue metabolites. As a consequence, their appearance depends on the magnetic field strength (B₀) and pulse sequence parameters such as B₁ strength, pulse shape and length, and interpulse delay, which presents a major problem for quantification and reproducibility of MTC and CEST effects. The use of higher B₀ can bring several advantages. In addition to higher detection sensitivity (signal-to-noise ratio, SNR), both MTC and CEST studies benefit from longer water T₁ allowing the saturation transferred to water to be retained longer. While MTC studies are non-specific at any field strength, CEST specificity is expected to increase at higher field because of a larger chemical shift dispersion of the resonances of interest (similar to MRS). In addition, shifting to a slower exchange regime at higher B₀ facilitates improved detection of the guanidinium protons of creatine and the inherently broad resonances of the amine protons in glutamate and the hydroxyl protons in myoinositol, glycogen, and glucosaminoglycans. Finally, due to the higher mobility of the contributing protons in CEST versus MTC, many new pulse sequences can be designed to more specifically edit for CEST signals and to remove MTC contributions.

Population neuroscience

Population neuroscience endeavors to identify influences shaping the human brain from conception onwards, thus generating knowledge relevant for building and maintaining brain health throughout the life span. This can be achieved by studying large samples of participants drawn from the general population and evaluated with state-of-the-art tools for assessing (a) genes and their regulation; (b) external and internal environments; and (c) brain properties. This chapter reviews the three elements of population neuroscience (principles, tools, innovations, limitations), and discusses future directions in this field.

Simultaneous multi-angular relaxometry of tissue with MRI (SMART MRI): Theoretical background and proof of concept

PURPOSE

Accurate measurement of tissue-specific relaxation parameters is an ultimate goal of quantitative MRI. The objective of this study is to introduce a new technique, simultaneous multiangular relaxometry of tissue with MRI (SMART MRI), which provides naturally coregistered quantitative spin density, longitudinal and transverse relaxation rate constant maps along with parameters characterizing magnetization transfer (MT) effects.

THEORY AND METHODS

SMART MRI is based on a gradient-recalled echo MRI sequence with multiple flip angles and multiple gradient echoes and a derived theoretical expression for the MR signal generated in this experimental conditions. The theory, based on Bloch-McConnell equations, takes into consideration cross-relaxation between two water pools: "free" and "bound" to macromolecules. It describes the role of cross-relaxation effects in formation of longitudinal and transverse relaxation of "free" water signal, thus providing background for measurements of these effects without using MT pulses. Bayesian analysis is used to optimize SMART MRI sequence parameters.

RESULTS

Data obtained on three participants demonstrate feasibility of the proposed approach.

CONCLUSION

SMART MRI provides quantitative measurements of longitudinal and transverse relaxation rate constants of "free" water signal affected by cross-relaxation effects. It also provides information on some essential MT parameters without requiring off-resonance MT pulses. Magn Reson Med 77:1296-1306, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Whole-Brain In-vivo Measurements of the Axonal G-Ratio in a Group of 37 Healthy Volunteers

The g-ratio, quantifying the ratio between the inner and outer diameters of a fiber, is an important microstructural characteristic of fiber pathways and is functionally related to conduction velocity. We introduce a novel method for estimating the MR g-ratio non-invasively across the whole brain using high-fidelity magnetization transfer (MT) imaging and single-shell diffusion MRI. These methods enabled us to map the MR g-ratio in vivo across the brain's prominent fiber pathways in a group of 37 healthy volunteers and to estimate the inter-subject variability. Effective correction of susceptibility-related distortion artifacts was essential before combining the MT and diffusion data, in order to reduce partial volume and edge artifacts. The MR g-ratio is in good qualitative agreement with histological findings despite the different resolution and spatial coverage of MRI and histology. The MR g-ratio holds promise as an important non-invasive biomarker due to its microstructural and functional relevance in neurodegeneration.

Magnetization transfer contrast-suppressed imaging of amide proton transfer and relayed nuclear overhauser enhancement chemical exchange saturation transfer effects in the human brain at 7T

PURPOSE

To use the variable delay multipulse (VDMP) chemical exchange saturation transfer (CEST) approach to obtain clean amide proton transfer (APT) and relayed Nuclear Overhauser enhancement (rNOE) CEST images in the human brain by suppressing the conventional magnetization transfer contrast (MTC) and reducing the direct water saturation contribution.

METHODS

The VDMP CEST scheme consists of a train of RF pulses with a specific mixing time. The CEST signal with respect to the mixing time shows distinguishable characteristics for protons with different exchange rates. Exchange rate filtered CEST images are generated by subtracting images acquired at two mixing times at which the MTC signals are equal, while the APT and rNOE-CEST signals differ. Because the subtraction is performed at the same frequency offset for each voxel and the CEST signals are broad, no B0 correction is needed.

RESULTS

MTC-suppressed APT and rNOE-CEST images of human brain were obtained using the VDMP method. The APT-CEST data show hyperintensity in gray matter versus white matter, whereas the rNOE-CEST images show negligible contrast between gray and white matter.

CONCLUSION

The VDMP approach provides a simple and rapid way of recording MTC-suppressed APT-CEST and rNOE-CEST images without the need for B0 field correction.

Biexponential longitudinal relaxation in white matter: Characterization and impact on T1 mapping with IR-FSE and MP2RAGE

PURPOSE

Magnetization transfer in white matter (WM) causes biexponential relaxation, but most quantitative T1 measurements fit data assuming monoexponential relaxation. The resulting monoexponential T1 estimate varies based on scan parameters and represents a source of variation between studies, especially at high fields. In this study, we characterized WM T1 relaxation and performed simulations to determine how to minimize this deviation.

METHODS

To characterize biexponential relaxation, four volunteers were scanned at 3T and 7T using inversion recovery fast spin echo (IR-FSE) with 13 inversion times (TIs). Three volunteers were scanned with IR-FSE using TIs chosen by simulations to reduce T1 deviation, and with MP2RAGE.

RESULTS

At 3T, the biexponential relaxation has a short component of T1  = 48 ms (9%) and a long component of T1  = 939 ms. At 7T the short component is T1  = 57 ms (11%) and the long component is 1349 ms (89%). For IR-FSE, acquiring four TIs with a minimum of 150 ms (3T) or 200 ms (7T) yielded monoexponential T1 estimates that match the long component to within 10 ms. For MP2RAGE, significant differences (90 ms at 3T, 125 ms at 7T) remain at all parameter values.

CONCLUSION

Many T1 mapping sequences yield robust estimates of the long T1 component with suitable choice of TIs, allowing reproducible, sequence-independent T1 values to be measured. However, this is not true of MP2RAGE in its current implementation. Magn Reson Med 75:2265-2277, 2016. © 2015 Wiley Periodicals, Inc.

Multivariate combination of magnetization transfer, T2* and B0 orientation to study the myelo-architecture of the in vivo human cortex

Recently, T2* imaging at 7Tesla (T) MRI was shown to reveal microstructural features of the cortical myeloarchitecture thanks to an increase in contrast-to-noise ratio. However, several confounds hamper the specificity of T2* measures (iron content, blood vessels, tissues orientation). Another metric, magnetization transfer ratio (MTR), is known to also be sensitive to myelin content and thus would be an excellent complementary measure because its underlying contrast mechanisms are different than that from T2*. The goal of this study was thus to combine MTR and T2* using multivariate statistics in order to gain insights into cortical myelin content. Seven healthy subjects were scanned at 7T and 3T to obtain T2* and MTR data, respectively. A multivariate myelin estimation model (MMEM) was developed, and consists in (i) normalizing T2* and MTR values and (ii) extracting their shared information using independent component analysis (ICA). B0 orientation dependence and cortical thickness were also computed and included in the model. Results showed high correlation between MTR and T2* in the whole cortex (r=0.76, p<10(-16)), suggesting that both metrics are partly driven by a common source of contrast, here assumed to be the myelin. Average MTR and T2* were respectively 31.0+/-0.3% and 32.1+/-1.4 ms. Results of the MMEM spatial distribution showed similar trends to that from histological work stained for myelin (r=0.77, p<0.01). Significant right-left differences were detected in the primary motor cortex (p<0.05), the posterior cingulate cortex (p<0.05) and the visual cortex (p<0.05). This study demonstrates that MTR and T2* are highly correlated in the cortex. The combination of MTR, T2*, CT and B0 orientation may be a useful means to study cortical myeloarchitecture with more specificity than using any of the individual methods. The MMEM framework is extendable to other contrasts such as T1 and diffusion MRI.

Steady pulsed imaging and labeling scheme for noninvasive perfusion imaging

PURPOSE

A steady pulsed imaging and labeling (SPIL) scheme is proposed to obtain high-resolution multislice perfusion images of mice brain using standard preclinical MRI equipment.

THEORY AND METHODS

The SPIL scheme repeats a pulsed arterial spin labeling (PASL) module together with a short mixing time to extend the temporal duration of the generated PASL bolus to the total experimental time. Multislice image acquisition takes place during the mixing times. The mixing time is also used for magnetization recovery following image acquisition. The new scheme is able to yield multislice perfusion images rapidly. The perfusion kinetic curve can be measured by a multipulsed imaging and labeling (MPIL) scheme, i.e., acquiring single-slice ASL signals before reaching steady-state in the SPIL sequence.

RESULTS

When applying the SPIL method to normal mice, and to mice with unilateral ischemia, high-resolution multislice (five slices) CBF images could be obtained in 8 min. Perfusion data from ischemic mice showed clear CBF reductions in ischemic regions. The SPIL method was also applied to postmortem mice, showing that the method is free from magnetization transfer confounds.

CONCLUSION

The new SPIL scheme provides for robust measurement of CBF with multislice imaging capability in small animals.

Puberty and testosterone shape the corticospinal tract during male adolescence

Some of the known sex differences in white matter emerge during adolescence. Here, we replicate and extend our previous findings of sex differences in the structure of the corticospinal tract (Perrin et al. 2009; Hervé et al. 2009). In a large normative sample of adolescents, we observed age × sex interactions in the signal intensity of T1-weighted (T1W) images (n = 941) and in magnetization transfer ratio (MTR; n = 761); both features were inversely associated with age in males but not in females. Moreover, we hypothesized that the age-related differences in CST structure exhibited by males would be mediated by differences in puberty stage and levels of bioavailable testosterone. We confirmed this prediction using mediation analysis with bootstrapping. These findings suggest that sex differences in the CST structure observed during male adolescence may be due to multiple processes associated with puberty, including (but not limited to) the rising levels of testosterone.

Adiposity is associated with structural properties of the adolescent brain

Obesity, a major risk factor for cardiometabolic disease, is associated with variations in a number of structural properties in the adult brain, as assessed with magnetic resonance imaging (MRI). In this study, we investigated the cross-sectional relationship between visceral fat (VF), total body fat (TBF) and three MRI parameters in the brains of typically developing adolescents: (i) T1-weighted (T1W) signal intensity; (ii) T1W signal contrast between white matter (WM) and gray matter (GM); and (iii) magnetization transfer ratio (MTR). In a community-based sample of 970 adolescents (12-18 years old, 466 males), VF was quantified using MRI, and total body fat was measured using a multifrequency bioimpedance. T1W images of the brain were used to determine signal intensity in lobar GM and WM, as well as WM:GM signal contrast. A magnetization transfer (MT) sequence of MT(ON) and MT(OFF) was used to obtain MTR in GM and WM. We found that both larger volumes of VF and more TBF were independently associated with higher signal intensity in WM and higher WM:GM signal contrast, as well as higher MTR in both GM and WM. These relationships were independent of a number of potential confounders, including age, sex, puberty stage, household income and height. Our results suggest that both visceral fat and fat deposited elsewhere in the body are associated independently with structural properties of the adolescent brain. We speculate that these relationships suggest the presence of adiposity-related variations in phospholipid composition of brain lipids.

Evidence for both compensatory plastic and disuse atrophy-related neuroanatomical changes in the blind

The behavioural and neurofunctional consequences of blindness are becoming increasingly well established, and it has become evident that the amount of reorganization is directly linked to the behavioural adaptations observed in the blind. However investigations of potential neuroanatomical changes resulting from blindness have yielded conflicting results as to the nature of the observed changes, because apparent loss of occipital tissue is difficult to reconcile with observed functional recruitment. To address this issue we used two complementary brain measures of neuroanatomy, voxel-based morphometry and magnetization transfer imaging, with the latter providing insight into myelin concentration through the magnetization transfer ratio. Both early and late blind, as well as sighted control subjects participated in the study and were tested on a series of auditory and tactile tasks to provide behavioural data that we could relate to neuroanatomy. The behavioural findings show that the early blind outperform the sighted in four of five tasks, whereas the late blind do so for only one. Moreover, correlations between the auditory and tactile performance of early blind individuals seem to indicate that they might benefit from some general-purpose compensatory plasticity mechanisms, as opposed to modality-specific ones. Neuroanatomical findings reveal three key findings: (i) occipital regions in the early blind have higher magnetization transfer ratio and grey matter concentration than in the sighted; (ii) behavioural performance of the blind is strongly predicted by magnetization transfer ratio and grey matter concentration in different occipital regions; and (iii) lower grey matter and white matter concentration was also found in other occipital areas in the early blind compared to the sighted. We thus show a clear dissociation between anatomical changes that are direct result of sensory deprivation and consequent atrophy, and those related to compensatory reorganization and behavioural adaptations. Moreover, the magnetization transfer ratio results also suggest that one mechanism for this reorganization may be related to increased myelination of intracortical neurons, or perhaps of fibres conveying information to and from remote locations.

The prognostic utility of MRI in clinically isolated syndrome: a literature review

For patients presenting with clinically isolated syndrome, the treating clinician needs to advise the patient on the probability of conversion to clinically definite multiple sclerosis. MR imaging may give useful prognostic information, and there is large body of literature pertaining to the use of MR imaging in assessing patients presenting with clinically isolated syndrome. This literature review evaluates the accuracy of MR imaging in predicting which patients with clinically isolated syndrome will go on to develop long-term disease and/or disability. New and emerging MR imaging technologies and their applicability to patients with clinically isolated syndrome are also considered.

Advanced MRI strategies for assessing spinal cord injury

Advanced magnetic resonance (MR) approaches permit the noninvasive quantification of macromolecular, functional, and physiological properties of biological tissues. In this chapter, we review the application of advanced MR techniques to the spinal cord. Macromolecular properties of the spinal cord can be studied using magnetization transfer (MT) MR, diffusion tensor imaging (DTI), Q-space diffusion spectroscopy, and selective detection of myelin water. The functional and metabolic status of the spinal cord can be studied using functional MRI (fMRI), perfusion imaging, and magnetic resonance spectroscopy (MRS). Finally, we consider the outlook for advanced MR studies in persons in whom metal hardware has been implanted to stabilize the cord. In spite of the spinal cord's diminutive size, its location deep within the body, and constant motion, recent work shows that the spinal cord can be studied using these advanced MR approaches.

Quantitative magnetization transfer imaging of human brain at 7 T

Quantitative magnetization transfer (qMT) imaging yields indices describing the interactions between free water protons and immobile macromolecular protons. These indices include the macromolecular to free pool size ratio (PSR), which has been shown to be correlated with myelin content in white matter. Because of the long scan times required for whole-brain imaging (≈20-30 min), qMT studies of the human brain have not found widespread application. Herein, we investigated whether the increased signal-to-noise ratio available at 7.0 T could be used to reduce qMT scan times. More specifically, we developed a selective inversion recovery (SIR) qMT imaging protocol with a i) novel transmit radiofrequency (B(1)(+)) and static field (B(0)) insensitive inversion pulse, ii) turbo field-echo readout, and iii) reduced TR. In vivo qMT data were obtained in the brains of healthy volunteers at 7.0 T using the resulting protocol (scan time≈40 s/slice, resolution=2 × 2 × 3 mm(3)). Reliability was also assessed in repeated acquisitions. The results of this study demonstrate that SIR qMT imaging can be reliably performed within the radiofrequency power restrictions present at 7.0 T, even in the presence of large B(1)(+) and B(0) inhomogeneities. Consistent with qMT studies at lower field strengths, the observed PSR values were higher in white matter (mean±SD=17.6 ± 1.3%) relative to gray matter (10.3 ± 1.6%) at 7.0 T. In addition, regional variations in PSR were observed in white matter. Together, these results suggest that qMT measurements are feasible at 7.0 T and may eventually allow for the high-resolution assessment of changes in composition throughout the normal and diseased human brain in vivo.

Advanced MRI strategies for assessing spinal cord injury

Advanced magnetic resonance (MR) approaches permit the noninvasive quantification of macromolecular, functional, and physiological properties of biological tissues. In this chapter, we review the application of advanced MR techniques to the spinal cord. Macromolecular properties of the spinal cord can be studied using magnetization transfer (MT) MR, diffusion tensor imaging (DTI), Q-space diffusion spectroscopy, and selective detection of myelin water. The functional and metabolic status of the spinal cord can be studied using functional MRI (fMRI), perfusion imaging, and magnetic resonance spectroscopy (MRS). Finally, we consider the outlook for advanced MR studies in persons in whom metal hardware has been implanted to stabilize the cord. In spite of the spinal cord's diminutive size, its location deep within the body, and constant motion, recent work shows that the spinal cord can be studied using these advanced MR approaches.

Fast bound pool fraction mapping using stimulated echoes

Magnetization transfer imaging advanced to an indispensible tool for investigating white matter changes. Quantitative magnetization transfer imaging methods allow the determination of the bound pool fraction (BPF), which is thought to be directly linked to myelin integrity. Long acquisition times and high specific absorption rates are still inhibiting broad in vivo utilization of currently available BPF mapping techniques. Herewith, a stimulated echoes amplitude modulation-based, single-shot echo planar imaging technique for BPF and T(1) quantification is presented at 3T. It allows whole brain mapping in 10-15 min and is low in specific absorption rates. The method was validated with different concentrations of bovine serum albumin (BSA) phantoms. Intra- and inter-subject variability was assessed in vivo. Phantom measurements verified linearity between bovine serum albumin concentrations and measured BPF, which was independent of T(1) variations. T(1) values in the phantoms correlated well with values provided by standard T(1) mapping methods. Intrasubject variability was minimal and mean regional BPFs of 10 volunteers (e.g., left frontal white matter=0.135 ± 0.003, right frontal white matter=0.129 ± 0.006) were in line with previously published data. Assessment of interhemispheric BPF differences revealed significantly higher BPF for the left brain hemisphere. To sum up, these results suggest the proposed method useful for cross-sectional and longitudinal studies of white matter changes in the human brain.

Chemical exchange saturation transfer (CEST): what is in a name and what isn't?

Chemical exchange saturation transfer (CEST) imaging is a relatively new magnetic resonance imaging contrast approach in which exogenous or endogenous compounds containing either exchangeable protons or exchangeable molecules are selectively saturated and after transfer of this saturation, detected indirectly through the water signal with enhanced sensitivity. The focus of this review is on basic magnetic resonance principles underlying CEST and similarities to and differences with conventional magnetization transfer contrast. In CEST magnetic resonance imaging, transfer of magnetization is studied in mobile compounds instead of semisolids. Similar to magnetization transfer contrast, CEST has contributions of both chemical exchange and dipolar cross-relaxation, but the latter can often be neglected if exchange is fast. Contrary to magnetization transfer contrast, CEST imaging requires sufficiently slow exchange on the magnetic resonance time scale to allow selective irradiation of the protons of interest. As a consequence, magnetic labeling is not limited to radio-frequency saturation but can be expanded with slower frequency-selective approaches such as inversion, gradient dephasing and frequency labeling. The basic theory, design criteria, and experimental issues for exchange transfer imaging are discussed. A new classification for CEST agents based on exchange type is proposed. The potential of this young field is discussed, especially with respect to in vivo application and translation to humans.

Fat-free MRI based on magnetization exchange

An MRI technique is proposed for complete fat signal elimination. This approach exploits the fact that water rapidly exchanges magnetization with protons in protein and membrane phospholipid of tissue and cells but does not exchange magnetization with triglyceride or fat protons in the tissue. Saturation of the proton signal from protein and membrane phospholipid thus results in partial saturation of the water proton signal, allowing acquisition of an image including a portion of the water signal and the full fat signal. Subtraction of this image from the standard image, containing both water and fat signals, results in an image in which all fat signal is cancelled. This fat-free image is sensitive to magnetization transfer and to water density and relaxation time, providing the possibility of additional contrast. Unlike most fat suppression techniques, this method is not compromised by the static or radiofrequency field heterogeneity and is equally efficient for all fat resonances independent of their chemical shift frequency.

Growth of white matter in the adolescent brain: myelin or axon?

White matter occupies almost half of the human brain. It contains axons connecting spatially segregated modules and, as such, it is essential for the smooth flow of information in functional networks. Structural maturation of white matter continues during adolescence, as reflected in age-related changes in its volume, as well as in its microstructure. Here I review recent observations obtained with magnetic resonance imaging in typically developing adolescents and point out some of the known variations in structural properties of white matter vis-à-vis brain function in health and disease. I conclude by re-focusing the interpretations of MR-based studies of white matter from myelin to axon.

Incidental magnetization transfer contrast by fat saturation preparation pulses in multislice Look-Locker echo planar imaging

In this study, it is demonstrated that fat saturation (FS) preparation (prep) pulses generate incidental magnetization transfer contrast (MTC) in multislice Look-Locker (LL) imaging. It is shown that frequency-selective FS prep pulses can invoke MTC through the exchange between free and motion-restricted protons. Simulation reveals that the fractional signal loss by these MTC effects is more severe for smaller flip angles (FAs), shorter repetition times (TRs), and greater number of slices (SN). These incidental MTC effects result in a signal attenuation at a steady state (up to 30%) and a T(1) measurement bias (up to 20%) when using inversion recovery (IR) LL echo-planar imaging (EPI) sequences. Furthermore, it is shown that water-selective MRI using binomial pulses has the potential to minimize the signal attenuation and provide unbiased T(1) measurement without fat artifacts in MR images.

Investigation of quantitative magnetisation transfer parameters of lesions and normal appearing white matter in multiple sclerosis

The aim of this study was to use quantitative magnetisation transfer (MT) imaging to assess the different pathological substrates of tissue damage in multiple sclerosis (MS) and examine whether the MT parameters may be used to explain the disability in relapsing remitting (RR) MS. Thirteen patients with RRMS and 14 healthy controls were prescribed conventional MRI and quantitative MT imaging at 3.0 T. A two-pool model of MT (where A refers to the free pool and B to the macromolecular pool) was fitted to the data yielding a longitudinal relaxation rate R(A), a relative size F of macromolecular pool, transverse relaxation times T(2) (A) and T(2) (B) for the two pools and a forward exchange rate RM(0) (B). The MT ratio (MTR) was also computed. The mean MT parameters of the normal appearing white matter (NAWM) and of lesions in patients, and of white matter in controls were estimated. MT parameters were significantly different between lesions and NAWM in patients, and between the NAWM and the white matter of controls (with the exception of T(2) (B) and the MTR). Two models were investigated using ordered logistic regression, with the expanded disability status scale (EDSS) as the dependent variable. In the first one, mean NAWM MT parameters and lesion load were entered as explanatory variables; in the second one, mean MT variables within lesions and lesion load were entered as explanatory variables. Unexpectedly, T(2) (B) was the parameter most significantly associated with EDSS in NAWM. This parameter might represent a weighted average of the relaxation times of spins with different molecular environments, and therefore its variation could indicate a change in the balance between subpopulations of macromolecular spins. Conversely, in lesions, RM(0) (B), T(2) (B), F, R(A), and lesion load significantly predicted disability only when combined together. This might reflect the complex interaction between demyelination, remyelination, gliosis, inflammation and axonal loss taking place within lesions.