Acute corticospinal tract diffusion tensor imaging predicts 6-month functional outcome after intracerebral haemorrhage

Diffusion tensor imaging assessments to investigate motor impairment recovery after minor basal ganglia hemorrhage post-stereotactic surgery

Objective

To investigate the efficacy of diffusion tensor imaging (DTI) in assessing the motor impairment resulting from minor basal ganglia hemorrhage post-stereotactic surgery.

Methods

A total of 104 patients with minor basal ganglia hemorrhages (hematoma volume ≤15 ml) underwent DTI within 48 h and 1 month post-treatment. Patients were divided into two groups: 42 in the experimental group, receiving stereotactic surgery and medication, and 62 in the control group, receiving medication alone. The corticospinal tract (CST) of the posterior limb of the internal capsule was the region of interest (ROI) for assessing mean FA values on both sides. Fugl-Meyer motor function (FMF) scores were recorded within 48 h and 1 month post-treatment, and Modified Rankin Scale (MRS) scores at 6 months.

Results

After 1 month of treatment, the FA values and FMF scores for the affected side of patients in the experimental group were 0.34 ± 0.17 and 67.84 ± 4.72, respectively, significantly surpassing those of the control group, which were 0.21 ± 0.06 and 45.38 ± 2.25 (P < 0.05). After 6 months of treatment, the experimental group exhibited MRS scores of 10 cases (23.81%) at grade 0, 12 cases (28.57%) at grade 1, 16 cases (38.10%) at grade 2, 2 cases (4.76%) at grade 3, 2 cases (4.76%) at grade 4, and 0 cases at grade 5. In contrast, the control group demonstrated 8 cases (12.90%) at grade 0, 12 cases (19.35%) at grade 1, 18 cases (29.03%) at grade 2, 15 cases (24.19%) at grade 3, 6 cases (9.68%) at grade 4, and 3 cases (4.84%) at grade 5. There are 18 cases (29.03%) in grade 2, 15 cases (24.19%) in grade 3, 6 cases (9.68%) in grade 4, and 3 cases (4.84%) in grade 5 within the control group. The experimental group showed a significantly better MRS score compared to the control group (P < 0.05).

Conclusion

DTI can accurately evaluate the structural integrity of the CST in patients with minor basal ganglia hemorrhages following stereotactic surgery, particularly regarding the CST pathways involved in motor control, providing valuable guidance for clinical treatment.

Diffusion Tensor Imaging 3D Tractography-Guided, Individualized, Transsulcul Approach for Subcortical Hematoma Evacuation Using BrainPath/Myriad

sICH (spontaneous intracerebral hemorrhage) is a major cause of death and disability. Traditional surgical evacuation, while beneficial, risks damaging healthy tissue. Minimally invasive surgery (MIS) offers a promising alternative. This study explores the feasibility and safety of diffusion tensor imaging (DTI)-guided, trans-sulcal MIS with BrainPath/Myriad NICO Corporation (Indianapolis, IN, USA) for sICH evacuation. DTI/tractography (DTT) visualizes critical pathways like the corticospinal tract (CST), aiding surgical planning and potentially predicting motor function recovery post-surgery. Our objectives include i) assessing the feasibility and safety of DTT-guided, trans-sulcal MIS with BrainPath/Myriad for sICH evacuation. ii) Evaluating DTT's utility in surgical planning and its potential role in predicting motor function recovery. Three sICH patients underwent pre-operative DTT with CST involvement graded A (direct injury) to E (displacement). Based on DTT, surgical trajectories using three trans-sulcal approaches were planned to avoid the CST. MIS with BrainPath/Myriad was performed aiming for <15 mL residual hematoma. Post-operative DTT and motor function follow-up (≥3 months) were conducted. Three patients completed pre- and post-operative DTT scans. All were middle-aged males with sympathomimetic abuse history. Two had Type A CST involvement, and one had Type D. Both Type A patients recovered well but showed no significant motor improvement. The Type D patient showed motor improvement. All patients completed the three-month follow-up. Our limited data suggests that DTI-guided, trans-sulcal MIS with BrainPath/Myriad for sICH evacuation is feasible and safe. DTT seems valuable for surgical planning and potentially predicts motor function recovery. Further studies with more patients are needed to confirm these findings.

SERPINA3 predicts long-term neurological outcomes and mortality in patients with intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a severe stroke subtype with high mortality and disability rates, and long-term outcomes among survivors remain unpredictable due to the lack of reliable biomarkers. In this study, spatial transcriptomics was used to analyze molecular profiles in autopsy brain tissues from chronic ICH patients, revealing distinct transcriptomic features in the thalamus and cortex, with common inflammatory characteristics such as gliosis, apoptosis, and immune activation. Serine proteinase inhibitor NA3 (SERPINA3) was significantly upregulated in both regions and co-expressed with astrocytes in the thalamus. Pathological studies in postmortem human tissues and mouse models confirmed elevated SERPINA3 expression, with murine Serpina3n showing a similar pattern in mice. Plasma analysis of 250 ICH patients and 250 healthy controls revealed significantly higher SERPINA3 levels in ICH patients, correlating with hemorrhage severity, National Institutes of Health Stroke Scale (NIHSS), and Glasgow Coma Scale (GCS) scores, and long-term functional outcomes. Higher SERPINA3 levels within 72 hours of hemorrhage onset were independently associated with worse functional recovery (mRS ≥ 3) and increased all-cause mortality at 6 and 12 months. Additionally, SERPINA3 levels at 7 days post-ictus correlated with white matter hyperintensities and poor cognitive performance at 6 months. These findings highlight SERPINA3 as a potential prognostic biomarker for ICH, warranting further investigation into its role in long-term neurological dysfunction and validation in larger prospective cohorts.

Associations Between Stroke Outcome Assessments and Automated Tractography Fractional Anisotropy Incorporating Age

OBJECTIVE

To evaluate the association between outcomes, including affected extremity functions and activities of daily living (ADL), and fractional anisotropy (FA) derived from automated tractography incorporating age among patients after stroke.

METHODS

This study enrolled stroke patients, and diffusion-tensor imaging was conducted during the second week. Standardized automated tractography was utilized to compute FA values in the corticospinal tract (CST), the inferior fronto-occipital fasciculus (IFOF), and the superior longitudinal fasciculus (SLF). Outcome evaluations were performed at discharge from our affiliated rehabilitation facility. Extremity functions were assessed using the total scores of the motor component of the Stroke Impairment Assessment Set (SIAS-motor). Independence levels in ADL were appraised through the motor and cognition components of the Functional Independence Measure (FIM). For each outcome measure, multivariate regression analysis incorporated the FA values of the CST, the IFOF, and the SLF, along with age.

RESULTS

Forty-two patients were enrolled in the final analytical database. Among the four explanatory variables, the CST emerged as the most influential factor for SIAS-motor scores. Conversely, age proved to be the primary determinant for both the motor and cognition components of FIM, surpassing the impact of FA metrics, including the CST and the IFOF.

CONCLUSION

The key influencing factors exhibited significant variations based on the targeted outcome assessments. Clinicians should be aware of these differences when utilizing neuroimaging techniques to predict stroke outcomes.

Involvement of the posterior limb of the internal capsule independently predicts the prognosis of patients with basal ganglia and thalamic hemorrhage

Background

Intracerebral hemorrhage (ICH) is the most lethal and devastating subtype of stroke. Basal ganglia hemorrhage and thalamic hemorrhage are the most common types of ICH, accounting for 50-70% of all ICH cases, leading to disability and death, and it involves the posterior limb of the internal capsule to varying degrees. In this study, we investigated the impact of varying degrees of the involvement of the posterior limb of the internal capsule on the prognosis of patients with basal ganglia and thalamic ICH and assessed whether it improves the predictive accuracy of the max-ICH score, an existing scale for ICH functional outcome.

Methods

This is a multicenter, retrospective, observational study. We graded the involvement of the posterior limb of the internal capsule according to the degree of compression and injury (called iICH, ranging from 0 to 4). An unfavorable outcome was defined as a 90-day modified Rankin Scale (mRS) of > 2. Multivariate logistic regression analysis was used to identify independent risk factors associated with unfavorable prognosis. The discrimination was verified using receiver operating characteristic curve (ROC) analysis, while the calibration was verified by the Hosmer-Lemeshow test.

Results

Of the 305 patients included, 188 from Nanfang Hospital were assigned to the development cohort, and 117 from Heyuan People's Hospital and Huadu District People's Hospital were assigned to the validation cohort. In the development cohort, iICH was identified as an independent factor of a 90-day unfavorable outcome, and the area under the ROC (AUC) was 0.774. When combined with the iICH, the AUC of max-ICH was significantly elevated from 0.816 to 0.866. Comparable results were found in the validation cohort.

Conclusions

Increased involvement of the posterior limb of the internal capsule is associated with a worse outcome in patients with basal ganglia and thalamic ICH.

Applicability of fractional anisotropy from standardized automated tractography for outcome prediction of patients after stroke

[Purpose] Diffusion-tensor fractional anisotropy has been used for outcome prediction in stroke patients. We assessed the clinical applicability of the two major fractional anisotropy methodologies-fractional anisotropy derived from segmentation maps in the standard brain (region of interest) and fractional anisotropy derived from standardized automated tractography-in relation to outcomes. [Participants and Methods] The study design was a retrospective survey of medical records collected from October 2021 to September 2022. Diffusion-tensor imaging was conducted in the second week after stroke onset. Outcomes were assessed using the total score of the motor component of the Stroke Impairment Assessment Set (null to full, 0 to 25). Correlations between fractional anisotropy and the outcomes were then assessed. [Results] Fourteen patients with hemorrhagic stroke were sampled. The fractional anisotropy from standardized automated tractography of the corticospinal tract on the lesion side (mean ± standard deviation, 0.403 ± 0.070) was significantly and tightly correlated (r=0.813) with the outcomes (13.4 ± 9.2), whereas the fractional anisotropy from a region of interest set in the cerebral peduncle on the lesion side (0.548 ± 0.064) was not significantly correlated with the outcomes (r=0.507). [Conclusion] The findings suggest that fractional anisotropy derived from standardized automated tractography can be more applicable to outcome prediction than that derived from a region of interest defined in the standard brain.

Whole-brain diffusion tensor imaging predicts 6-month functional outcome in acute intracerebral haemorrhage

INTRODUCTION

Small vessel disease (SVD) causes most spontaneous intracerebral haemorrhage (ICH) and is associated with widespread microstructural brain tissue disruption, which can be quantified via diffusion tensor imaging (DTI) metrics: mean diffusivity (MD) and fractional anisotropy (FA). Little is known about the impact of whole-brain microstructural alterations after SVD-related ICH. We aimed to investigate: (1) association between whole-brain DTI metrics and functional outcome after ICH; and (2) predictive ability of these metrics compared to the pre-existing ICH score.

METHODS

Sixty-eight patients (38.2% lobar) were retrospectively included. We assessed whole-brain DTI metrics (obtained within 5 days after ICH) in cortical and deep grey matter and white matter. We used univariable logistic regression to assess the associations between DTI and clinical-radiological variables and poor outcome (modified Rankin Scale > 2). We determined the optimal predictive variables (via LASSO estimation) in: model 1 (DTI variables only), model 2 (DTI plus non-DTI variables), model 3 (DTI plus ICH score). Optimism-adjusted C-statistics were calculated for each model and compared (likelihood ratio test) against the ICH score.

RESULTS

Deep grey matter MD (OR 1.04 [95% CI 1.01-1.07], p = 0.010) and white matter MD (OR 1.11 [95% CI 1.01-1.23], p = 0.044) were associated (univariate analysis) with poor outcome. Discrimination values for model 1 (0.67 [95% CI 0.52-0.83]), model 2 (0.71 [95% CI 0.57-0.85) and model 3 (0.66 [95% CI 0.52-0.82]) were all significantly higher than the ICH score (0.62 [95% CI 0.49-0.75]).

CONCLUSION

Our exploratory study suggests that whole-brain microstructural disruption measured by DTI is associated with poor 6-month functional outcome after SVD-related ICH. Whole-brain DTI metrics performed better at predicting recovery than the existing ICH score.

Improving delineation of the corticospinal tract in the monkey brain scanned with conventional DTI by using a compressed sensing based algorithm

Background

The corticospinal tract (CST) is a major tract for motor function. It can be impaired by stroke. Its degeneration is associated with stroke outcome. Diffusion tensor imaging (DTI) tractography plays an important role in assessing fiber bundle integrity. However, it is limited in detecting crossing fibers in the brain. The crossing fiber angular resolution of intra-voxel structure (CFARI) algorithm shows potential to resolve complex fibers in the brain. The objective of the present study was to improve delineation of CST pathways in monkey brains scanned by conventional DTI.

Methods

Healthy rhesus monkeys were scanned by diffusion MRI with 128 diffusion encoding directions to evaluate the CFARI algorithm. Four monkeys with ischemic occlusion were also scanned with DTI (b = 1000 s/mm², 30 diffusion directions) at 6, 48, and 96 hours post stroke. CST fibers were reconstructed with DTI and CFARI-based tractography and evaluated. A two-way repeated MANOVA was used to determine significances of changes in DTI indices, tract number, and volumes of the CST between hemispheres or post-stroke time points.

Results

CFARI algorithm revealed substantially more fibers originated from the ventral premotor cortex in healthy and stroke monkey brains than DTI tractography. In addition, CFARI showed better sensitivity in detecting CST abnormality than DTI tractography following stroke.

Conclusion

CFARI significantly improved delineation of the CST in the brain scanned by DTI with 30 gradient directions. It showed better sensitivity in detecting abnormity of the CST following stroke. Preliminary results suggest that CFARI could facilitate prediction of function outcomes after stroke.

Plasma Neurofilament Light Chain Predicts Mortality and Long-Term Neurological Outcomes in Patients with Intracerebral Hemorrhage

Patients with intracerebral hemorrhage (ICH) often suffer from heterogeneous long-term neurological deficits, such as cognitive decline. Our ability to measure secondary brain injury to predict the long-term outcomes of these patients is limited. We investigated whether the blood neurofilament light chain (NfL) can monitor brain injury and predict long-term outcomes in patients with ICH. We enrolled 300 patients with first-episode ICH within 24 h recruited in the Chinese Cerebral Hemorrhage Mechanisms and Intervention study cohort from January 2019 to June 2020. Patients were prospectively followed up for 12 months. Blood samples were collected from 153 healthy participants. Plasma NfL levels determined using a single-molecule array revealed a biphasic increase in plasma NfL in ICH patients compared to healthy controls, with the first peak at around 24 h and a second elevation from day 7 through day 14 post-ICH. Plasma NfL levels were positively correlated with hemorrhage volume, National Institute of Health Stroke Scale, and Glasgow Coma Scale scores of ICH patients. Higher NfL concentration within 72 h after ictus was independently associated with 6- and 12-month worsened functional outcomes (modified Rankin Scale ≥ 3) and higher all-cause mortality. Magnetic resonance imaging and cognitive function evaluation were available for 26 patients at 6 months post-ICH, and NfL levels measured 7 days post-ictus correlated with decreased white matter fiber integrity and poor cognitive function at 6 months after stroke. These findings suggest that blood NfL is a sensitive marker for monitoring axonal injury post-ICH and can predict long-term functional ability and survival.