How to investigate oxygen supply, uptake, and utilization simultaneously by interleaved NMR imaging and spectroscopy of the skeletal muscle

Sequence building block for magnetic resonance spectroscopy on Siemens VE-series scanners

We present a sequence building block (SBB) that embeds magnetic resonance spectroscopy (MRS) into another sequence on the Siemens VE platform without any custom hardware. This enables dynamic studies such as functional MRS (fMRS), dynamic shimming and frequency correction, and acquisition of navigator images for motion correction. The SBB supports nonlocalised spectroscopy (free induction decay), STimulated Echo Acquisition Mode single voxel spectroscopy, and 1D, 2D and 3D phase-encoded chemical shift imaging. It can embed 1H or X-nuclear MRS into a 1H sequence; and 1H-MRS into an X-nuclear sequence. We demonstrate integration into the vendor's gradient-recalled echo sequence. We acquire test data in phantoms with three coils (31P/1H, 13C/1H and 2H/1H) and in two volunteers on a 7-T Terra MRI scanner. Fifteen lines of code are required to insert the SBB into a sequence. Spectra and images are acquired successfully in all cases in phantoms, and in human abdomen and calf muscle. Phantom comparison of signal-to-noise ratio and linewidth showed that the SBB has negligible effects on image and spectral quality, except that it sometimes produces a nuclear Overhauser effect (NOE) signal enhancement for multinuclear applications in line with conventional 1H NOE pulses. Our new SBB embeds MRS into a host imaging or spectroscopy sequence in 15 lines of code. It allows homonuclear and heteronuclear interleaving. The package is available through the standard C2P procedure. We hope this will lower the barrier for entry to studies applying dynamic fMRS and for online motion correction and B0-shim updating.

Interleaved and simultaneous multi-nuclear magnetic resonance in vivo. Review of principles, applications and potential

Magnetic resonance signals from different nuclei can be excited or received at the same time,rendering simultaneous or rapidly interleaved multi-nuclear acquisitions feasible. The advan-tages are a reduction of total scan time compared to sequential multi-nuclear acquisitions or that additional information from heteronuclear data is obtained at thesame time and anatomical position. Information content can be qualitatively increased by delivering a more comprehensive MR-based picture of a transient state (such as an exercise bout). Also, combiningnon-proton MR acquisitions with ¹ Hinformation (e.g., dynamic shim updates and motion correction) can be used to improve data quality during long scans and benefits image coregistration. This work reviews the literature on interleaved and simultaneous multi-nuclear MRI and MRS in vivo. Prominent use cases for this methodology in clinical and research applications are brain and muscle, but studies have also been carried out in other targets, including the lung, knee, breast and heart. Simultaneous multi-nuclear measurements in the liver and kidney have also been performed, but exclusively in rodents. In this review, a consistent nomenclature is proposed, to help clarify the terminology used for this principle throughout the literature on in-vivo MR. An overview covers the basic principles, the technical requirements on the MR scanner and the implementations realised either by MR system vendors or research groups, from the early days until today. Considerations regarding the multi-tuned RF coils required and heteronuclear polarisation interactions are briefly discussed, and fields for future in-vivo applications for interleaved multi-nuclear MR pulse sequences are identified.

Repeatability of multinuclear interleaved acquisitions with nuclear Overhauser enhancement effect in dynamic experiments in the calf muscle at 3T

PURPOSE

To evaluate the repeatability of multinuclear interleaved ¹ H/³¹ P NMR dynamic acquisitions in skeletal muscle and the impact of nuclear Overhauser enhancement (nOe) on the ³¹ P results at 3T in exercise-recovery and ischemia-hyperemia paradigms.

METHODS

A ¹ H/³¹ P interleaved pulse sequence was used to measure every 2.5 s a perfusion-weighted image, a T 2 ∗ map, a ³¹ P spectrum and 32 ¹ H spectra sensitive to deoxymyoglobin. 21 subjects performed a plantar flexion exercise and after recovery underwent an 8-min lower leg ischemia. The procedure was repeated in visit 2 with 12 subjects. An additional exercise bout without ¹ H excitation was appended to visit 1. Individual ¹ H RF pulse nOe was measured at rest in every visit.

RESULTS

Repeatability scores (coefficient of variation, Bland-Altman analysis) were similar to those found in the literature using similar mono-nuclear acquisitions. |Pi]/[PCr], pH drop, creatine rephosphorylation rate (τ_PCr ), maximum perfusion, time to peak perfusion, and blood flow post-exercise showed high reliability (intraclass correlation coefficient > 0.7), whereas hemodynamic results from reactive hyperemia showed higher repeatability. After accounting for nOe, which increased Pi and PCr signal-to-noise ratio by 30%, no differences in ³¹ P results were observed between interleaved and ³¹ P MRS-only acquisitions. τ_PCr was unaffected by nOe.

CONCLUSION

The method shows good repeatability for both paradigms while simultaneously providing multiple dynamic data sets on a clinical scanner. The nOe effects were accounted for on a per-subject and per-visit basis using a short ³¹ P reference scan. This multiparametric approach has a multitude of applications for the study of oxygen utilization and ATP turnover in the muscle.

Skeletal Muscle Quantitative Nuclear Magnetic Resonance Imaging and Spectroscopy as an Outcome Measure for Clinical Trials

Recent years have seen tremendous progress towards therapy of many previously incurable neuromuscular diseases. This new context has acted as a driving force for the development of novel non-invasive outcome measures. These can be organized in three main categories: functional tools, fluid biomarkers and imagery. In the latest category, nuclear magnetic resonance imaging (NMRI) offers a considerable range of possibilities for the characterization of skeletal muscle composition, function and metabolism. Nowadays, three NMR outcome measures are frequently integrated in clinical research protocols. They are: 1/ the muscle cross sectional area or volume, 2/ the percentage of intramuscular fat and 3/ the muscle water T2, which quantity muscle trophicity, chronic fatty degenerative changes and oedema (or more broadly, “disease activity”), respectively. A fourth biomarker, the contractile tissue volume is easily derived from the first two ones. The fat fraction maps most often acquired with Dixon sequences have proven their capability to detect small changes in muscle composition and have repeatedly shown superior sensitivity over standard functional evaluation. This outcome measure will more than likely be the first of the series to be validated as an endpoint by regulatory agencies. The versatility of contrast generated by NMR has opened many additional possibilities for characterization of the skeletal muscle and will result in the proposal of more NMR biomarkers. Ultra-short TE (UTE) sequences, late gadolinium enhancement and NMR elastography are being investigated as candidates to evaluate skeletal muscle interstitial fibrosis. Many options exist to measure muscle perfusion and oxygenation by NMR. Diffusion NMR as well as texture analysis algorithms could generate complementary information on muscle organization at microscopic and mesoscopic scales, respectively. ³¹P NMR spectroscopy is the reference technique to assess muscle energetics non-invasively during and after exercise. In dystrophic muscle, ³¹P NMR spectrum at rest is profoundly perturbed, and several resonances inform on cell membrane integrity. Considerable efforts are being directed towards acceleration of image acquisitions using a variety of approaches, from the extraction of fat content and water T2 maps from one single acquisition to partial matrices acquisition schemes. Spectacular decreases in examination time are expected in the near future. They will reinforce the attractiveness of NMR outcome measures and will further facilitate their integration in clinical research trials.

Simultaneous and interleaved acquisition of NMR signals from different nuclei with a clinical MRI scanner

Purpose

Modification of a clinical MRI scanner to enable simultaneous or rapid interleaved acquisition of signals from two different nuclei.

Methods

A device was developed to modify the local oscillator signal fed to the receive channel(s) of an MRI console. This enables external modification of the frequency at which the receiver is sensitive and rapid switching between different frequencies. Use of the device was demonstrated with interleaved and simultaneous ³¹P and ¹H spectroscopic acquisitions, and with interleaved ³¹P and ¹H imaging.

Results

Signal amplitudes and signal‐to‐noise ratios were found to be unchanged for the modified system, compared with data acquired with the MRI system in the standard configuration.

Conclusion

Interleaved and simultaneous ¹H and ³¹P signal acquisition was successfully demonstrated with a clinical MRI scanner, with only minor modification of the RF architecture. While demonstrated with ³¹P, the modification is applicable to any detectable nucleus without further modification, enabling a wide range of simultaneous and interleaved experiments to be performed within a clinical setting. Magn Reson Med 76:1636–1641, 2016. © 2015 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.

Noninvasive estimation of oxygen consumption in human calf muscle through combined NMR measurements of ASL perfusion and T₂ oxymetry

The objective of this work was to demonstrate the feasibility of measuring muscle O2 consumption (V˙O2) noninvasively with a combination of functional nuclear magnetic resonance (NMR) imaging methods, and to verify that changes in muscle V˙O2 can be detected with a temporal resolution compatible with physiological investigation and patient ease. T2-based oxymetry of arterial and venous blood was combined with the arterial-spin labeling (ASL)-based determination of muscle perfusion. These measurements were performed on 8 healthy volunteers under normoxic and hypoxic conditions in order to assess the sensitivity of measurements over a range of saturation values. Blood samples were drawn simultaneously and used to titrate blood T2 measurements versus hemoglobin O2 saturation (%HbO2) in vitro. The in vitro calibration curve of blood T2 fitted very well with the %HbO2 (r(2): 0.95). The in vivo venous T2 measurements agreed well with the in vitro measurements (intraclass correlation coefficient 0.82, 95% confidence interval 0.61-0.91). Oxygen extraction at rest decreased in the calf muscles subjected to hypoxia (p = 0.031). The combination of unaltered muscle perfusion and pinched arteriovenous O2 difference (p = 0.038) pointed towards a reduced calf muscle V˙O2 during transient hypoxia (p = 0.018). The results of this pilot study confirmed that muscle O2 extraction and V˙O2 can be estimated noninvasively using a combination of functional NMR techniques. Further studies are needed to confirm the usefulness in a larger sample of volunteers and patients.

Skeletal muscle perfusion and oxygenation assessed by dynamic NMR imaging and spectroscopy

Muscle perfusion, and capillary and intramyocytic oxygenation can be probed non-invasively in vivo by functional NMR techniques, arterial spin labelling combined with imaging, BOLD imaging and deoxymyoglobin (1)H spectroscopy, respectively. After adequate adaptation of equipment, these measurements can be performed in parallel, together with (31)P spectroscopy and provide a comprehensive analysis of various facets of oxygen metabolism in dynamic protocols, in humans as well as in animal models.

Fast monitoring of T(1) , T(2) , and relative proton density (M(0) ) changes in skeletal muscles using an IR-TrueFISP sequence

PURPOSE

To investigate the feasibility of fast and simultaneous assessment of T(1) , T(2) , and M(0) (relative proton density) changes in skeletal muscle studies using an inversion recovery true fast imaging with steady-state precession (TrueFISP) sequence.

MATERIALS AND METHODS

NMR signal dynamics in calf muscles were analyzed under four different conditions: intravenous injection of a low-molecular weight Gd contrast agent (CA), postarterial occlusion reactive hyperemia, local cooling, and an exercise bout. Experiments were conducted on a clinical 3T whole-body scanner.

RESULTS

At rest, average muscle T(1) and T(2) values obtained from the IR-TrueFISP experiments were 1.34 ± 0.13 seconds and 45 ± 5 msec, respectively (median ± standard deviation). 1) Noticeable T(1) decreases (ΔT(1) max ≈-30%) were measured in the calf muscles after CA injection, while no significant changes were observed for T(2) and M(0) . 2) T(2) increased rapidly during reactive hyperemia and reached a peak value (+6%) at about 1 minute postischemia. During ischemia, a significant decrease was observed only in the soleus muscle. No significant paradigm-related changes in M(0) and T(1) were noted in all muscle groups, except in the m. soleus (ΔT(1) ≈+1% during reactive hyperemia). 3) Opposite variations in muscle T(1) (ΔT(1) max ≈-30%) and M(0) (ΔM(0) max ≈+25%) associated with local cooling were detected. 4) Concomitant changes in T(1) (ΔT(1) max ≈+15%), T(2) (ΔT(2) max ≈+35%), and M(0) (ΔM(0) max ≈+16%) were observed in the activated muscles following the exercise bout.

CONCLUSION

IR-TrueFISP was sufficiently fast and sensitive to detect small and transient T(1) , T(2) , and M(0) changes in the calf muscles under different experimental conditions. The sequence offers a time-resolution adequate to track rapid physiological adaptations in skeletal muscle.

The paradox of oxidative stress and exercise with advancing age

Aging, vascular function, and exercise are thought to have a common link in oxidative stress. Both antioxidant supplementation and exercise training have been identified as interventions that may reduce oxidative stress, but their interaction in older humans is not well understood.

Measuring perfusion and bioenergetics simultaneously in mouse skeletal muscle: a multiparametric functional-NMR approach

A totally noninvasive set-up was developed for comprehensive NMR evaluation of mouse skeletal muscle function in vivo. Dynamic pulsed arterial spin labeling-NMRI perfusion and blood oxygenation level-dependent (BOLD) signal measurements were interleaved with (31)P NMRS to measure both vascular response and oxidative capacities during stimulated exercise and subsequent recovery. Force output was recorded with a dedicated ergometer. Twelve exercise bouts were performed. The perfusion, BOLD signal, pH and force-time integral were obtained from mouse legs for each exercise. All reached a steady state after the second exercise, justifying the pointwise summation of the last 10 exercises to compensate for the limited (31)P signal. In this way, a high temporal resolution of 2.5  s was achieved to provide a time constant for phosphocreatine (PCr) recovery (τ(PCr)). The higher signal-to-noise ratio improved the precision of τ(PCr) measurement [coefficient of variation (CV) = 16.5% vs CV = 49.2% for a single exercise at a resolution of 30  s]. Inter-animal summation confirmed that τ(PCr) was stable at steady state, but shorter (89.3 ± 8.6  s) than after the first exercise (148  s, p < 0.05). This novel experimental approach provides an assessment of muscle vascular response simultaneously to energetic function in vivo. Its pertinence was illustrated by observing the establishment of a metabolic steady state. This comprehensive tool offers new perspectives for the study of muscle pathology in mice models.

Intermittent electrical stimulation redistributes pressure and promotes tissue oxygenation in loaded muscles of individuals with spinal cord injury

Deep tissue injury (DTI) is a severe form of pressure ulcer that originates at the bone-muscle interface. It results from mechanical damage and ischemic injury due to unrelieved pressure. Currently, there are no established clinical methods to detect the formation of DTI. Moreover, despite the many recommended methods for preventing pressure ulcers, none so far has significantly reduced the incidence of DTI. The goal of this study was to assess the effectiveness of a new electrical stimulation-based intervention, termed intermittent electrical stimulation (IES), in ameliorating the factors leading to DTI in individuals with compromised mobility and sensation. Specifically, we sought to determine whether IES-induced contractions in the gluteal muscles can 1) reduce pressure in tissue surrounding bony prominences susceptible to the development of DTI and 2) increase oxygenation in deep tissue. Experiments were conducted in individuals with spinal cord injury, and two paradigms of IES were utilized to induce contractions in the gluteus maximus muscles of the seated participants. Changes in surface pressure around the ischial tuberosities were assessed using a pressure-sensing mattress, and changes in deep tissue oxygenation were indirectly assessed using T₂*-weighted magnetic resonance imaging (MRI) techniques. Both IES paradigms significantly reduced pressure around the bony prominences in the buttocks by an average of 10-26% (P < 0.05). Furthermore, both IES paradigms induced significant increases in T₂* signal intensity (SI), indicating significant increases in tissue oxygenation, which were sustained for the duration of each 10-min trial (P < 0.05). Maximal increases in SI ranged from 2-3.3% (arbitrary units). Direct measurements of oxygenation in adult rats revealed that IES produces up to a 100% increase in tissue oxygenation. The results suggest that IES directly targets factors contributing to the development of DTI in people with reduced mobility and sensation and may therefore be an effective method for the prevention of deep pressure ulcers.

Antioxidants and aging: NMR-based evidence of improved skeletal muscle perfusion and energetics

We sought to examine the potential role of oxidative stress on skeletal muscle function with advancing age. Nuclear magnetic resonance (NMR) was employed to simultaneously assess muscle perfusion (arterial spin labeling) and energetics ((31)P NMR spectroscopy) in the lower leg of young (26 + or - 5 yr, n = 6) and older (70 + or - 5 yr, n = 6) healthy volunteers following the consumption of either placebo (PL) or an oral antioxidant (AO) cocktail (vitamins C and E and alpha-lipoic acid), previously documented to decrease plasma free radical concentration. NMR measurements were made during and after 5 min of moderate intensity (approximately 5 W) plantar flexion exercise. AO administration significantly improved end-exercise perfusion (AO, 50 + or - 5, and PL, 43 + or - 4 ml x 100 g(-1) x min(-1)) and postexercise perfusion area under the curve (AO, 1,286 + or - 236, and PL, 866 + or - 144 ml/100 g) in older subjects, whereas AO administration did not alter hemodynamics in the young group. Concomitantly, muscle oxidative capacity (time constant of phosphocreatine recovery, tau) was improved following AO in the older (AO, 43 + or - 1, and PL, 51 + or - 7 s) but not the young (AO, 54 + or - 5, and PL, 48 + or - 7 s) group. These findings support the concept that oxidative stress may be partially responsible for the age-related decline in skeletal muscle perfusion during physical activity and reveal a muscle metabolic reserve capacity in the elderly that is accessible under conditions of improved perfusion.

Multiparametric NMR-based assessment of skeletal muscle perfusion and metabolism during exercise in elderly persons: preliminary findings

BACKGROUND

Aging is associated with a decline in exercise capacity that may be attributable to maladaptations in both skeletal muscle perfusion and metabolism; yet very little is known regarding the real-time, within-muscle interplay between these parameters during physical activity. Therefore, we utilized an unique nuclear magnetic resonance sequence to concomitantly examine changes in lower leg skeletal muscle perfusion and metabolism.

METHODS

In young (26+/-5 years, n=6) and older (70+/-5 years, n=6) healthy volunteers, arterial spin labeling measurements of muscle perfusion were combined with 31 Phosphorous (31P) nuclear magnetic resonance spectroscopy to monitor high-energy phosphate metabolites during and after 5 minutes of moderate-intensity (approximately 5W) plantar flexion exercise.

RESULTS

Compared with young, end-exercise perfusion was diminished in older participants (43+/-10 mL/100 g/minute, old; 60+/-7 mL/100 g.minute, young), accompanied by greater phosphocreatine (PCr) depletion (-28%+/-12%, old; -19%+/-7%, young) and elevated inorganic phosphate/PCr (0.41+/-0.2, old; 0.24+/-0.09, young); yet the time constant for PCr recovery (tau, an index of muscle oxidative capacity) was similar between groups (51+/-17 seconds, old; 48+/-7 seconds, young).

CONCLUSIONS

Together, these preliminary data provide evidence of an age-related decline in tissue perfusion and increased "metabolic stress" during exercise but demonstrate that overall oxidative capacity in the elderly does not appear negatively affected by this relatively hypoperfused state.

Models of muscle contraction and energetics

How does skeletal muscle manage to regulate the pathways of ATP synthesis during large-scale changes in work rate while maintaining metabolic homeostasis remains unknown. The classic model of metabolic regulation during muscle contraction states that accelerating ATP utilization leads to increasing concentrations of ADP and Pi, which serve as substrates for oxidative phosphorylation and thus accelerate ATP synthesis. An alternative model states that both the ATP demand and ATP supply pathways are simultaneously activated. Here, we review experimental and computational models of muscle contraction and energetics at various organizational levels and compare them with respect to their pros and cons in facilitating understanding of the regulation of energy metabolism during exercise in the intact organism.

Musculoskeletal spectroscopy

Magnetic resonance spectroscopy (MRS) of skeletal muscle has been successfully applied by physiologists over several decades, particularly for studies of high-energy phosphates (by (31)P-MRS) and glycogen (by (13)C-MRS). Unfortunately, the observation of these heteronuclei requires equipment that is typically not available on clinical MR scanners, such as broadband capability and a second channel for decoupling and nuclear Overhauser enhancement (NOE). On the other hand, (1)H-MR spectra of skeletal muscle can be acquired on many routine MR systems and also provide a wealth of physiological information. In particular, studies of intramyocellular lipids (IMCL) attract physiologists and endocrinologists because IMCL levels are related to insulin resistance and thus can lead to a better understanding of major health problems in industrial countries. The combination of (1)H-, (13)C-, and (31)P-MRS gives access to the major long- and short-term energy sources of skeletal muscle. This review summarizes the technical aspects and unique MR-methodological features of the different nuclei. It reviews clinical studies that employed MRS of one or more nuclei, or combinations of MRS with other MR modalities. It also illustrates that MR spectra contain additional physiological information that is not yet used in routine clinical applications.

Muscle blood flow and oxygenation measured by NMR imaging and spectroscopy

Tissue perfusion and oxygenation in many organs can be evaluated by various NMR techniques. This review focuses on the specificities, limitations and adaptations of the NMR tools available to investigate perfusion and oxygenation in the skeletal muscle of humans and animal models. A description of how they may be used simultaneously is provided as well. 1H NMR spectroscopy of myoglobin (Mb) monitors intramyocytic oxygenation. It measures the level of deoxy-Mb, from which Mb concentration, Mb desaturation/resaturation rates, muscle oxygenation changes and intracellular partial oxygen pressure (pO2) can be calculated. Positive and negative blood oxygen level-dependent (BOLD) contrasts exist in skeletal muscle. BOLD contrasts primarily reflect changes in capillary-venous oxygenation, but are also directly or indirectly dependent on muscle blood volume, perfusion, vascular network architecture and angulation, relative to the main magnetic field. Arterial spin labelling (ASL) techniques, having high spatial and temporal resolution, are the methods of choice to quantify and map skeletal muscle perfusion non-invasively. Limitations of ASL are poor contrast-to-noise ratio and sensitivity to movement; however, with the introduction of specific adaptations, it has been proven possible to measure skeletal muscle perfusion at both rest and during exercise. The possibility of combining these NMR measurements with others into a single dynamic protocol is most interesting. The 'multiparametric functional (mpf) NMR' concept can be extended to include the evaluation of muscle energy metabolism simultaneously with 31P NMR or with lactate double quantum filtered 1H NMR spectroscopy, an approach which would make NMR an exceptional tool for non-invasive investigations of integrative physiology and biochemistry in skeletal muscle in vivo.

Dynamic MRS and MRI of skeletal muscle function and biomechanics

MR is a powerful technique for studying the biomechanical and functional properties of skeletal muscle in vivo in health and disease. This review focuses on 31P, 1H and 13C MR spectroscopy for assessment of the dynamics of muscle metabolism and on dynamic 1H MRI methods for non-invasive measurement of the biomechanical and functional properties of skeletal muscle. The information thus obtained ranges from the microscopic level of the metabolism of the myocyte to the macroscopic level of the contractile function of muscle complexes. The MR technology presented plays a vital role in achieving a better understanding of many basic aspects of muscle function, including the regulation of mitochondrial activity and the intricate interplay between muscle fiber organization and contractile function. In addition, these tools are increasingly being employed to establish novel diagnostic procedures as well as to monitor the effects of therapeutic and lifestyle interventions for muscle disorders that have an increasing impact in modern society.