Feasibility of 7 T 39 K/ 23 Na Magnetic Resonance Imaging for assessing muscular ion balance in hypokalemic periodic paralysis

OBJECTIVES

Recently introduced potassium-39-( 39 K)-MRI provides a noninvasive approach to assess typically high intracellular K + -levels and can be combined with sodium-23-( 23 Na)-MRI. The aim of this study was to evaluate 39 K/ 23 Na muscle ion homeostasis in hypokalemic periodic paralysis (HypoPP), a rare muscular ion channelopathy, using 7 T MRI.

MATERIALS AND METHODS

Lower legs of patients with HypoPP and healthy controls were prospectively examined between August 2022 and July 2023 (case-control study). Scanning protocol at 3 T included T 1 -weighted, T 2 -weighted STIR sequences, a 6-point-Dixon-type gradient echo and a T2-mapping sequence. 39 K/ 23 Na data were acquired at 7 T using acquisition-weighted Stack-of-Stars sequences. Apparent tissue 39 K/ 23 Na concentrations (aTPC/aTSC) were calculated after correcting for partial-volume and relaxation effects and corrected for proton-density fat-fractions to account for fatty replacement. A 23 Na-inversion-recovery ( 23 Na-IR) sequence served to introduce a stronger intracellular weighting. Differences in central tendency between the HypoPP and control groups and correlations were analyzed.

RESULTS

Thirteen HypoPP-participants and 13 controls were included. Extent of fatty replacement/edema-like changes varied highly with the gastrocnemius medialis muscle most affected. The HypoPP group showed significantly increased aTSC in all 7 analyzed muscles and decreased aTPC in 3 specific muscles. Across all muscles, the mean aTSC was higher in the HypoPP group (median: 33.4 vs 22.5 mM, mean ± SD: 34.3 ± 6.8 vs 21.0 ± 4.8 mM, P < 0.001), whereas the mean aTPC was lower (98.7 vs 109.0 mM, 97.9 ± 12.0 vs 108.7 ± 10.4 mM, P = 0.02). The 23 Na-IR signal was strongly correlated with aTSC (r = 0.77, P < 0.001).

CONCLUSIONS

Combined 39 K/ 23 Na MRI at 7 T demonstrated alterations of sodium and potassium ion homeostasis in HypoPP. These findings could be helpful for a better pathophysiological understanding of HypoPP and may aid in future studies to assess disease extent or monitor treatment efficacy.

Determination of Tissue Potassium and Sodium Concentrations in Dystrophic Skeletal Muscle Tissue Using Combined Potassium (39K) and Sodium (23Na) MRI at 7 T

Combined 23Na/39K MRI at 7 T can highlight ion disturbances in skeletal muscle tissue. In this work, we investigated if the apparent tissue potassium concentration (aTPC) can be determined in fatty replaced muscles of patients with facio-scapulo-humeral muscular dystrophy (FSHD) and if it can provide additional information to the fat replacement and the apparent tissue sodium concentration (aTSC). The lower leg of 14 patients (six females, eight males; mean age 47.7 ± 14.0 years) with genetically confirmed FSHD and 11 healthy controls (four females, seven males; mean age 47.0 ± 14.0 years) was examined at a 7-T MR system using a dual-tuned 23Na/39K birdcage RF coil. In addition, qualitative and quantitative 1H MR measurements were performed at 7 T to assess the fat replacement and water accumulation. The aTPC and aTSC were determined in seven different muscle regions based on five external references phantoms and corrected for partial volume effects, relaxation biases, and reduced ion concentrations in fat. Results are expressed as median (interquartile range). The measured aTPC was strongly reduced in fat-replaced muscles and was close to zero in totally fat replaced muscles (aTPC = 4.3 mM [2.7 mM] for FF > 80%). After correction of aTPC values for reduced potassium concentration in fat, aTPCfc values of patients in muscles with low or moderate fat fraction (FF < 30%) were similar to values of healthy subjects (patients: aTPCfc = 85.6 mM [21.7 mM]; controls: aTPCfc = 83.2 mM [22.3 mM]). However, muscles with FF > 30% showed reduced aTPCfc and increased aTSCfc compared with healthy controls (aTPCfc = 28.9 mM [46.2 mM], aTSCfc = 42.3 mM [17.6 mM]; controls: aTSCfc = 15.0 mM [4.6 mM], aTPCfc = 83.2 mM [22.3 mM]). No correlations were observed between the aTPCfc and aTSCfc, or between aTPCfc and water T2. We showed that a determination of the aTPC in dystrophic skeletal muscles is feasible using 39K MRI at 7 T. Measured changes in aTPCfc were greater than sole fat replacement and might therefore be used as an additional quantitative measure for dystrophic muscle tissue.

Recent technical developments and clinical research applications of sodium (23Na) MRI

Sodium is an essential ion that plays a central role in many physiological processes including the transmembrane electrochemical gradient and the maintenance of the body's homeostasis. Due to the crucial role of sodium in the human body, the sodium nucleus is a promising candidate for non-invasively assessing (patho-)physiological changes. Almost 10 years ago, Madelin et al. provided a comprehensive review of methods and applications of sodium (23Na) MRI (Madelin et al., 2014) [1]. More recent review articles have focused mainly on specific applications of 23Na MRI. For example, several articles covered 23Na MRI applications for diseases such as osteoarthritis (Zbyn et al., 2016, Zaric et al., 2020) [2,3], multiple sclerosis (Petracca et al., 2016, Huhn et al., 2019) [4,5] and brain tumors (Schepkin, 2016) [6], or for imaging certain organs such as the kidneys (Zollner et al., 2016) [7], the brain (Shah et al., 2016, Thulborn et al., 2018) [8,9], and the heart (Bottomley, 2016) [10]. Other articles have reviewed technical developments such as radiofrequency (RF) coils for 23Na MRI (Wiggins et al., 2016, Bangerter et al., 2016) [11,12], pulse sequences (Konstandin et al., 2014) [13], image reconstruction methods (Chen et al., 2021) [14], and interleaved/simultaneous imaging techniques (Lopez Kolkovsky et al., 2022) [15]. In addition, 23Na MRI topics have been covered in review articles with broader topics such as multinuclear MRI or ultra-high-field MRI (Niesporek et al., 2019, Hu et al., 2019, Ladd et al., 2018) [16-18]. During the past decade, various research groups have continued working on technical improvements to sodium MRI and have investigated its potential to serve as a diagnostic and prognostic tool. Clinical research applications of 23Na MRI have covered a broad spectrum of diseases, mainly focusing on the brain, cartilage, and skeletal muscle (see Fig. 1). In this article, we aim to provide a comprehensive summary of methodological and hardware developments, as well as a review of various clinical research applications of sodium (23Na) MRI in the last decade (i.e., published from the beginning of 2013 to the end of 2022).

MRI of Potassium and Sodium Enables Comprehensive Analysis of Ion Perturbations in Skeletal Muscle Tissue After Eccentric Exercise

OBJECTIVES

The aims were to investigate if potassium ( 39 K) magnetic resonance imaging (MRI) can be used to analyze changes in the apparent tissue potassium concentration (aTPC) in calf muscle tissue after eccentric exercise and in delayed-onset muscle soreness, and to compare these to corresponding changes in the apparent tissue sodium concentration (aTSC) measured with sodium ( 23 Na) MRI.

MATERIALS AND METHODS

Fourteen healthy subjects (7 female, 7 male; 25.0 ± 2.8 years) underwent 39 K and 23 Na MRI at a 7 T MR system, as well as 1 H MRI at a 3 T MR system. Magnetic resonance imaging data and blood samples were collected at baseline (t0), directly after performing eccentric exercise (t1) and 48 hours after exercise (t2). Self-reported muscle soreness was evaluated using a 10-cm visual analog scale for pain (0, no pain; 10, worst pain) at t0, t1, and t2. Quantification of aTPC/aTSC was performed after correcting the measured 39 K/ 23 Na signal intensities for partial volume and relaxation effects using 5 external reference phantoms. Edema volume and 1 H T 2 relaxation times were determined based on the 1 H MRI data. Participants were divided according to their increase in creatine kinase (CK) level into high (CK t2 ≥ 10·CK t0 ) and low CK (CK t2 < 10·CK t0 ) subjects.

RESULTS

Blood serum CK and edema volume were significantly increased 48 hours after exercise compared with baseline ( P < 0.001). Six participants showed a high increase in blood serum CK level at t2 relative to baseline, whereas 8 participants had only a low to moderate increase in blood serum CK. All participants reported increased muscle soreness both at rest and when climbing stairs at t1 (0.4 ± 0.7; 1.4 ± 1.2) and t2 (1.6 ± 1.4; 4.8 ± 1.9) compared with baseline (0 ± 0; 0 ± 0). Moreover, aTSC was increased at t1 in exercised muscles of all participants (increase by 57% ± 24% in high CK, 73% ± 33% in low CK subjects). Forty-eight hours after training, subjects with high increase in blood serum CK still showed highly increased aTSC (increase by 79% ± 57% compared with t0). In contrast, aTPC at t2 was elevated in exercised muscles of low CK subjects (increase by 19% ± 11% compared with t0), in which aTSC had returned to baseline or below. Overall, aTSC and aTPC showed inverse evolution, with changes in aTSC being approximately twice as high as in aTPC.

CONCLUSIONS

Our results showed that 39 K MRI is able to detect changes in muscular potassium concentrations caused by eccentric exercise. In combination with 23 Na MRI, this enables a more holistic analysis of tissue ion concentration changes.

Assessing muscle-specific potassium concentrations in human lower leg using potassium magnetic resonance imaging

Noninvasively assessing tissue potassium concentrations (TPCs) using potassium magnetic resonance imaging (³⁹ K MRI) could give valuable information on physiological processes connected to various pathologies. However, because of inherently low ³⁹ K MR image resolution and strong signal blurring, a reliable measurement of the TPC is challenging. The aim of this work was to investigate the feasibility of a muscle-specific TPC determination with a focus on the influence of a varying residual quadrupolar interaction in human lower leg muscles. The quantification accuracy of a muscle-specific TPC determination was first assessed using simulated ³⁹ K MRI data. In vivo ³⁹ K and corresponding sodium (²³ Na) MRI data of healthy lower leg muscles (n = 14, seven females) were acquired on a 7-T MR system using a double-resonant ²³ Na/³⁹ K birdcage Tx/Rx RF coil. Additional ¹ H MR images were acquired on a 3-T MR system and used for tissue segmentation. Quantification of TPC was performed after a region-based partial volume correction (PVC) using five external reference phantoms. Simulations not only underlined the importance of PVC for correctly assessing muscle-specific TPC values, but also revealed the strong impact of a varying residual quadrupolar interaction between different muscle regions on the measured TPC. Using ³⁹ K T₂ ^* decay curves, we found significantly higher residual quadrupolar interaction in tibialis anterior muscle (TA; ω_q  = 194 ± 28 Hz) compared with gastrocnemius muscle (medial/lateral head, GM/GL; ω_q  = 151 ± 25 Hz) and soleus muscle (SOL; ω_q  = 102 ± 32 Hz). If considered in the PVC, TPC in individual muscles was similar (TPC = 98 ± 11/96 ± 14/99 ± 8/100 ± 12 mM in GM/GL/SOL/TA). Comparison with tissue sodium concentrations suggested that residual quadrupolar interactions might also influence the ²³ Na MRI signal of lower leg muscles. A TPC determination of individual lower leg muscles is feasible and can therefore be applied in future studies. Considering a varying residual quadrupolar interaction for PVC of ³⁹ K MRI data is essential to reliably assess potassium concentrations in individual muscles.

Fast in vivo 23 Na imaging and T 2 ∗ mapping using accelerated 2D-FID UTE magnetic resonance spectroscopic imaging at 3 T: Proof of concept and reliability study

PURPOSE

To implement an accelerated MR-acquisition method allowing to map T 2 ∗ relaxation and absolute concentration of sodium within skeletal muscles at 3T.

METHODS

A fast-UTE-2D density-weighted concentric-ring-trajectory ²³ Na-MRSI technique was used to acquire 64 time points of FID with a spectral bandwidth of 312.5 Hz with an in-plane resolution of 2.5 × 2.5 mm² in ~15 min. The fast-relaxing ²³ Na signal was localized with a single-shot, inversion-recovery-based, non-echo (SIRENE) outer volume suppression (OVS) method. The sequence was verified using simulation and phantom studies before implementing it in human calf muscles. To evaluate the 2D-SIRENE-MRSI (UTE = 0.55 ms) imaging performance, it was compared to a 3D-MRI (UTE = 0.3 ms) sequence. Both data sets were acquired within 2 same-day sessions to assess repeatability. The T 2 ∗ values were fitted voxel-by-voxel using a biexponential model for the 2D-MRSI data. Finally, intra-subject coefficients of variation (CV) were estimated.

RESULTS

The MRSI-FID data allowed us to map the fast and slow components of T 2 ∗ in the calf muscles. The spatial distributions of ²³ Na concentration for both MRSI and 3D-MRI acquisitions were significantly correlated (P < .001). The test-retest analysis rendered high repeatability for MRSI with a CV of 5%. The mean T 2 Fast ∗ in muscles was 0.7 ± 0.1 ms (contribution fraction = 37%), whereas T 2 Slow ∗ was 13.2 ± 0.2 ms (63%). The mean absolute muscle ²³ Na concentration calculated from the T 2 ∗ -corrected data was 28.6 ± 3.3 mM.

CONCLUSION

The proposed MRSI technique is a reliable technique to map sodium's absolute concentration and T 2 ∗ within a clinically acceptable scan time at 3T.

Towards accelerated quantitative sodium MRI at 7 T in the skeletal muscle: Comparison of anisotropic acquisition- and compressed sensing techniques

PURPOSE

To compare three anisotropic acquisition schemes and three compressed sensing (CS) approaches for accelerated tissue sodium concentration (TSC) quantification using ²³Na MRI at 7 T.

MATERIALS AND METHODS

Three anisotropic 3D-radial acquisition sequences were evaluated using simulations, phantom- and in vivo TSC measurements: An anisotropic density-adapted 3D-radial sequence (3DPR-C), a 3D acquisition-weighted density-adapted stack-of-stars sampling scheme (SOS) and a SOS approach with golden-ratio rotation (SOS-GR). Eight healthy volunteers were examined at a 7 Tesla MRI system. TSC measurements of the calf were conducted with a nominal spatial resolution of Δx = (3.0 × 3.0 × 15.0) mm³ and a field of view of (156.0 × 156.0 × 240.0) mm³ for multiple undersampling factors (USF). Three CS reconstructions were evaluated: Total variation CS (TV-CS), 3D dictionary-learning compressed sensing (3D-DLCS) and TV-CS with a block matching prior (TV-BL-CS). Results of the simulations and measurements were compared to a simulated ground truth (GT) or a fully sampled reference measurement (FS), respectively. The deviation of the mean TSC evaluated in multiple ROI (mE_GT/FS) and the normalized root-mean-squared error (NRMSE) for simulations were evaluated for CS and NUFFT reconstructions.

RESULTS

In simulations, the SOS-GR yielded the lowest NRMSE and mE_GT (< 4%) with NUFFT for an acquisition time (TA) of less than 2 min. CS further improved the results. In simulations and measurements, the best TSC quantification results were obtained with 3D-DLCS and SOS-GR (lowest NRMSE, mE_GT < 2.6% in simulations, mE_GT < 10.7% for phantom measurements and mE_FS < 6% in vivo) with an USF = 4.1 (TA < 2 min). TV-CS showed no or only slight improvements to NUFFT. The results of TV-BL-CS were similar to 3D-DLCS.

DISCUSSION

The TA for TSC measurements could be reduced to less than 2 min by using adapted sequences such as SOS-GR and CS reconstruction approaches such as 3D-DLCS or TV-BL-CS, while the quantitative accuracy stays comparable to a fully sampled NUFFT reconstruction (approx. 8 min TA). In future, the lower TA could improve clinical applicability of TSC measurements.

Combined imaging of potassium and sodium in human skeletal muscle tissue at 7 T

PURPOSE

To validate the feasibility of quantitative combined potassium (³⁹ K) and sodium (²³ Na) MRI in human calf muscle tissue, as well as to evaluate the reproducibility of the apparent tissue potassium concentration (aTPC) and apparent tissue sodium concentration (aTSC) determination in healthy muscle tissue.

METHODS

Quantitative ²³ Na and ³⁹ K MRI acquisition protocols were implemented on a 7 T MR system. A double-resonant ²³ Na/³⁹ K birdcage RF coil was used. Measurements of human lower leg were performed in a total acquisition time of TA_Na = 10:54 min/TA_K = 8:06 min and using a nominal spatial resolution of 2.5 × 2.5 × 15 mm³ /7.5 × 7.5 × 30 mm³ for ²³ Na/³⁹ K MRI. Two aTSC and aTPC examinations in muscle tissue were performed during the same day on 10 healthy subjects.

RESULTS

The proposed acquisition and postprocessing workflow for ²³ Na and ³⁹ K MRI data sets provided reproducible aTSC and aTPC measurements. In human calf muscle tissue, the coefficient of variation between scan and re-scan was 5.7% for both aTSC and aTPC determination. Overall, mean values of aTSC = (17 ± 1) mM and aTPC = (85 ± 5) mM were measured. Moreover, for ³⁹ K in calf muscle tissue, T 2 ∗ components of T 2 f ∗ = (1.2 ± 0.2) ms and T 2 s ∗ = (7.9 ± 0.9) ms, as well as a residual quadrupolar interaction of ω q ¯ = (143 ± 17) Hz, were determined. The fraction of the fast component was f = (58 ± 4)%.

CONCLUSION

Using the presented measurement and postprocessing approach, a reproducible aTSC and aTPC determination using ²³ Na and ³⁹ K MRI at 7 T in human skeletal muscle tissue is feasible in clinically acceptable acquisition durations.

Frontiers of Sodium MRI Revisited: From Cartilage to Brain Imaging

Sodium magnetic resonance imaging (²³ Na-MRI) is a highly promising imaging modality that offers the possibility to noninvasively quantify sodium content in the tissue, one of the most relevant parameters for biochemical investigations. Despite its great potential, due to the intrinsically low signal-to-noise ratio (SNR) of sodium imaging generated by low in vivo sodium concentrations, low gyromagnetic ratio, and substantially shorter relaxation times than for proton (¹ H) imaging, ²³ Na-MRI is extremely challenging. In this article, we aim to provide a comprehensive overview of the literature that has been published in the last 10-15 years and which has demonstrated different technical designs for a range of ²³ Na-MRI methods applicable for disease diagnoses and treatment efficacy evaluations. Currently, a wider use of 3.0T and 7.0T systems provide imaging with the expected increase in SNR and, consequently, an increased image resolution and a reduced scanning time. A great interest in translational research has enlarged the field of sodium MRI applications to almost all parts of the body: articular cartilage tendons, spine, heart, breast, muscle, kidney, and brain, etc., and several pathological conditions, such as tumors, neurological and degenerative diseases, and others. The quantitative parameter, tissue sodium concentration, which reflects changes in intracellular sodium concentration, extracellular sodium concentration, and intra-/extracellular volume fractions is becoming acknowledged as a reliable biomarker. Although the great potential of this technique is evident, there must be steady technical development for ²³ Na-MRI to become a standard imaging tool. The future role of sodium imaging is not to be considered as an alternative to ¹ H MRI, but to provide early, diagnostically valuable information about altered metabolism or tissue function associated with disease genesis and progression. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 1.

Assessing the variability of 23 Na MRI in skeletal muscle tissue: Reproducibility and repeatability of tissue sodium concentration measurements in the lower leg at 3 T

The goal of this study was to evaluate the reproducibility and repeatability of tissue sodium concentration (TSC) measurements using ²³ Na MRI in skeletal muscle tissue. ²³ Na MRI was performed at 3 T on the right lower leg of eight healthy volunteers (aged 28 ± 4 years). The examinations were repeated at the same site after ~ 22 weeks to assess the variability over a medium-term period. Additionally, they were scanned at a second site shortly before or shortly after the first visit (within 3 weeks) to evaluate the inter-site reproducibility. Moreover, we analysed the effect of B₀ correction on the variability. Coefficients of variations (CVs) from mean TSC values as well as Bland-Altman plots were used to assess intra-site repeatability and inter-site reproducibility. In phantom measurements, the B₀ correction improved the quantitative accuracy. We observed differences of up to 4.9 mmol/L between the first and second visit and a difference of up to 3.7 mmol/L between the two different sites. The CV for the medium-term repeatability was 15% and the reproducibility CV was 9%. The Bland-Altman plots indicated high agreement between the visits in all muscle regions. The systematic bias of -0.68 mmol/L between site X and Y (P = 0.03) was slightly reduced to -0.64 mmol/L after B₀ correction (P = 0.04). This work shows that TSC measurements in healthy skeletal muscle tissue can be performed with good repeatability and reproducibility, which is of importance for future longitudinal or multicentre studies.