Relationship of hippocampus and amygdala to coronal MRI landmarks

Correlation of Preoperative Hippocampal Volume Measured with Magnetic Resonance Imaging and Emergence from General Anaesthesia in Elective Neurosurgical Patients: An Observational Study

BACKGROUND AND OBJECTIVES

The electrophysiological process of emergence from general anesthesia (GA) commences from deeper structures of the brain rather than the cortex. The phylogenetically old parts of the brain (hippocampus) are the first to recover during emergence. Study objectives were to evaluate and predict the effect of preoperative hippocampal volume (HV) measured using MRI with emergence from GA and delayed extubation in patients undergoing elective neurosurgical procedures.

METHODS

Patients aged 18-65 years of age scheduled for elective neurosurgical procedures under GA with GCS = 15 were recruited into the prospective cohort. Those who underwent excision of the hippocampus, amygdala, and temporal lobe pathology were excluded. Bilateral HVs and total brain volume were measured preoperatively using MRI brain. GA was induced by thiopentone, fentanyl, and vecuronium and maintained with sevoflurane. At the end of the surgery, sevoflurane was turned off, and a fresh gas flow of 6 L min-1 oxygen was set, allowing patients to wake up by "no contact technique." Time elapsed from turning off sevoflurane till the onset of different phases of emergence was measured. The patterns of emergence were assessed using GCS and Riker Sedation-Agitation Scale.

RESULTS

The complete data of 125 patients of 1192 screened for recruitment were analyzed. The median time for extubation was 13 minutes (IQR 9-16). The average bilateral standardized HV had a statistically significant negative correlation with the time to extubation (r = -0.185; P = 0.039). Average of bilateral standardized HV <2097 mm3 predicts delayed extubation with a specificity: 70.7%, sensitivity: 51.2% and AUC: 0.672, CI 0.524-0.724. Standardized dominant HV <1925 mm3 also predicts delayed extubation with specificity: 78%, sensitivity: 46.4% and AUC: 0.635, CI 0.533-0.738.

CONCLUSION

Neurosurgical patients with larger average HV might lead to early extubation, vocalization, and faster gaining of orientation after GA.

External cortical landmarks for localization of the hippocampus: Application for temporal lobectomy and amygdalohippocampectomy

Background:

Accessing the hippocampus for amygdalohippocampectomy and minimally invasive procedures, such as depth electrode placement, require an accurate knowledge regarding the location of the hippocampus.

Methods:

The authors removed 10 human cadaveric brains from the cranium and observed the relationships between the lateral temporal neocortex and the underlying hippocampus. They then measured the distance between the hippocampus and superficial landmarks. The authors also validated their study using magnetic resonance imaging (MRI) scans of 10 patients suffering from medial temporal lobe sclerosis where the distance from the hippocampal head to the anterior temporal tip was measured.

Results:

In general, the length of the hippocampus was along the inferior temporal sulcus and inferior aspect of the middle temporal gyrus. Although the hippocampus tended to be more superiorly located in female specimens and on the left side, this did not reach statistical significance. The length of the hippocampus tended to be shorter in females, but this too failed to reach statistical significance. The mean distance from the anterior temporal tip to the hippocampal head was identical in the cadavers and MRIs of patients with medial temporal lobe sclerosis.

Conclusions:

Additional landmarks for localizing the underlying hippocampus may be helpful in temporal lobe surgery. Based on this study, there are relatively constant anatomical landmarks between the hippocampus and overlying temporal cortex. Such landmarks may be used in localizing the hippocampus during amygdalohippocampectomy and depth electrode implantation in verifying the accuracy of image-guided methods and as adjuvant methodologies when these latter technologies are not used or are unavailable.

A protocol for manual segmentation of medial temporal lobe subregions in 7 Tesla MRI

Recent advances in MRI and increasing knowledge on the characterization and anatomical variability of medial temporal lobe (MTL) anatomy have paved the way for more specific subdivisions of the MTL in humans. In addition, recent studies suggest that early changes in many neurodegenerative and neuropsychiatric diseases are better detected in smaller subregions of the MTL rather than with whole structure analyses. Here, we developed a new protocol using 7 Tesla (T) MRI incorporating novel anatomical findings for the manual segmentation of entorhinal cortex (ErC), perirhinal cortex (PrC; divided into area 35 and 36), parahippocampal cortex (PhC), and hippocampus; which includes the subfields subiculum (Sub), CA1, CA2, as well as CA3 and dentate gyrus (DG) which are separated by the endfolial pathway covering most of the long axis of the hippocampus. We provide detailed instructions alongside slice-by-slice segmentations to ease learning for the untrained but also more experienced raters. Twenty-two subjects were scanned (19-32 yrs, mean age = 26 years, 12 females) with a turbo spin echo (TSE) T2-weighted MRI sequence with high-resolution oblique coronal slices oriented orthogonal to the long axis of the hippocampus (in-plane resolution 0.44 × 0.44 mm2) and 1.0 mm slice thickness. The scans were manually delineated by two experienced raters, to assess intra- and inter-rater reliability. The Dice Similarity Index (DSI) was above 0.78 for all regions and the Intraclass Correlation Coefficients (ICC) were between 0.76 to 0.99 both for intra- and inter-rater reliability. In conclusion, this study presents a fine-grained and comprehensive segmentation protocol for MTL structures at 7 T MRI that closely follows recent knowledge from anatomical studies. More specific subdivisions (e.g. area 35 and 36 in PrC, and the separation of DG and CA3) may pave the way for more precise delineations thereby enabling the detection of early volumetric changes in dementia and neuropsychiatric diseases.

Superficial cortical landmarks for localization of the hippocampus: Application for temporal lobectomy and amygdalohippocampectomy

Background:

Accessing the hippocampus for amygdalohippocampectomy and procedures such as depth electrode placement requires accurate knowledge regarding the location of the hippocampus.

Methods:

The authors removed 10 human cadaveric brains (20 sides) from their crania, noted relationships between the lateral temporal neocortex and underlying hippocampus, and measured the distance between the hippocampus and superficial landmarks.

Results:

Mean distances were as follows: 3.8 cm from the tip of the temporal lobe to the head of the hippocampus; 6.5 cm from the tip of the temporal lobe to the junction of the fornix and hippocampus; and 3.5 cm between the tail and head of the hippocampus. The head of the hippocampus ranged from 0 to 5 mm inferior to the inferior temporal sulcus. The tail of the hippocampus ranged from 2.2 to 7 mm superior to the inferior temporal sulcus. In two specimens, the tail was deep to the superior temporal sulcus. Generally the length of the hippocampus was along the inferior temporal sulcus and inferior aspect of the middle temporal gyrus. The hippocampus tended to be more superiorly located and shorter in females and left sides, but this was not statistically significant.

Conclusions:

Additional landmarks for localizing the underlying hippocampus may be helpful in temporal lobe surgery. Our study showed relatively constant anatomic landmarks between the hippocampus and overlying temporal cortex that may help localize the hippocampus during amygdalohippocampectomy and depth electrode implantation, verify the accuracy of image-guided methods, and used as adjuvant methodologies when these latter technologies are unavailable.

Internal structural changes in the hippocampus observed on 3-tesla MRI in patients with mesial temporal lobe epilepsy

OBJECTIVE

Hippocampal sclerosis (HS) is observed in many intractable, mesial temporal lobe epilepsy (MTLE) patients. We aimed to delineate the internal structural changes (ISC) shown as loss of internal architecture in the hippocampus on 3-Tesla magnetic resonance imaging (3T-MRI) due to its higher spatial resolution.

METHODS

We studied 12 MTLE patients who exhibited unilateral HS on conventional 1.5 Tesla-MRI. Using 3T-MRI, high resolution T2-weighted coronal images of the hippocampus were investigated by visual inspection without the use of detailed clinical information. In addition, tissue samples obtained from four patients who underwent epilepsy surgery were analyzed histopathologically.

RESULTS

In addition to hippocampal atrophy (HA) in the abnormal side, blurring of the low-intensity streak, i.e., ISC, in the hippocampus was seen in 12 patients and atrophy or high signal intensity was observed in Ammon's horn or the dentate gyrus in nine patients. After four patients underwent epilepsy surgery, tissue samples showed astrogliosis and a loss of pyramidal neurons in the hippocampal body, concordant with ISC or HA on MRI examination.

CONCLUSION

High-resolution MRI suggests that minute internal structural changes in the hippocampus reflect neuronal cell loss or gliosis, possibly in the early stage, and also show laterality of changes more sensitively. Different internal structural changes could further subclassify HS and may predict the surgical outcomes of seizure control based on the clinicopathological correlation.

Smaller head of the hippocampus in Gulf War-related posttraumatic stress disorder

Reductions in hippocampal volume and impairment in short-term verbal memory have been reported in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and in women with abuse-related PTSD. The present investigation evaluated hippocampal volume and memory in Gulf War veterans. This research is timely given the ongoing war in Iraq and the anticipated high rates of PTSD among returning combat soldiers. Fourteen veterans with PTSD related to traumatic experiences during the Gulf War (1990-1991), 23 deployed veterans without PTSD, 22 non-deployed reservists and 29 healthy civilians were studied. Volumes of the hippocampus, temporal lobe, and whole brain were measured on coronal MRI scans, and hippocampal mediated memory function was evaluated. The head of the hippocampus was the only subregion that was significantly smaller in Gulf War veterans with PTSD than in healthy civilians. Deployed veterans with PTSD, deployed veterans without PTSD, and non-deployed reservists had significantly smaller whole hippocampal volume and lower scores on immediate and delayed verbal and visual retrieval compared with healthy civilians.

Sequential 123I-iododexetimide scans in temporal lobe epilepsy: comparison with neuroimaging scans (MR imaging and 18F-FDG PET imaging)

PURPOSE

Muscarinic acetylcholine receptors (mAChRs) play an important role in the generation of seizures. Single-photon emission computed tomography (SPECT) with 12I-iododexetimide (IDEX) depicts tracer uptake by mAChRs. Our aims were to: (a) determine the optimum time for interictal IDEX SPECT imaging; (b) determine the accuracy of IDEX scans in the localisation of seizure foci when compared with video EEG and MR imaging in patients with temporal lobe epilepsy (TLE); (c) characterise the distribution of IDEX binding in the temporal lobes and (d) compare IDEX SPECT and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in identifying seizure foci.

METHODS

We performed sequential scans using IDEX SPECT imaging at 0, 3, 6 and 24 h in 12 consecutive patients with refractory TLE undergoing assessment for epilepsy surgery. Visual and region of interest analyses of the mesial, lateral and polar regions of the temporal lobes were used to compare IDEX SPECT, FDG PET and MR imaging in seizure onset localisation.

RESULTS

The 6-h IDEX scan (92%; kappa=0.83, p=0.003) was superior to the 0-h (36%; kappa=0.01, p>0.05), 3-h (55%; kappa=0.13, p>0.05) and 24-h IDEX scans in identifying the temporal lobe of seizure origin. The 6-h IDEX scan correctly predicted the temporal lobe of seizure origin in two patients who required intracranial EEG recordings to define the seizure onset. Reduced ligand binding was most marked at the temporal pole and mesial temporal structures. IDEX SPECT was superior to interictal FDG PET (75%; kappa=0.66, p=0.023) in seizure onset localisation. MR imaging was non-localising in two patients in whom it was normal and in another patient in whom there was bilateral symmetrical hippocampal atrophy.

CONCLUSION

The 6-h IDEX SPECT scan is a viable alternative to FDG PET imaging in seizure onset localisation in TLE.

Hippocampal volume, memory, and cortisol status in major depressive disorder: effects of treatment

BACKGROUND

Depression has been linked to stress, memory deficits, and hypercortisolemia. However, the relationships between depression, hippocampal structure and function, and cortisol levels are unclear and the effects of antidepressant treatment on the measures are not well studied.

METHODS

Whole hippocampal volume, performance on verbal and visual declarative memory function and cortisol status was evaluated in 38 subjects with major depressive disorder (MDD) and 33 healthy subjects. All measures were repeated in a subgroup (n = 22) of depressed patients after successful selective serotonin reuptake inhibitor (SSRI) treatment.

RESULTS

Hippocampal volume was not significantly different between patients with untreated MMD and healthy subjects, after controlling for whole brain volume, age and gender. However, depressed subjects had significantly greater deficits in delayed memory and percent retention on the verbal portion of the Wechsler Memory Scale-Revised (WMS-R) compared with healthy subjects, without significant differences in visual memory, attention, vigilance, or distractibility. Baseline plasma or urinary free cortisol (UFC) was not related to either hippocampal volume or memory deficits. Successful treatment with antidepressants did not change hippocampal volume but did result in a significant improvement in memory function and a reduction in UFC excretion.

CONCLUSIONS

Medication-free nonelderly depressed outpatients without alcohol dependence or adverse experiences in childhood had normal hippocampal volume. Focal declarative memory deficits in depression supported localized hippocampal dysfunction in depressed patients. Treatment with antidepressants significantly improved memory and depression but did not alter hippocampal volume, suggesting that antidepressants may improve hippocampal function in the absence of detectable structural changes.

Reduced serotonin type 1A receptor binding in panic disorder

Recent animal models suggest that disturbances in serotonin type-1A receptor (5-HT(1A)R) function may contribute to chronic anxiety, although it is not clear at all whether such models constitute relevant models for panic disorder (PD) in humans. The selective 5-HT(1A)R radioligand [18F]trans-4-fluoro-N-2-[4-(2-methoxyphenyl)piperazin-1-yl]ethyl]-N-(2-pyridyl)cyclohexanecarboxamide (FCWAY) permits in vivo assessment of central 5-HT(1A)R binding using positron emission tomography (PET). We studied 16 unmedicated symptomatic outpatients with PD and 15 matched healthy controls. Seven patients had an additional diagnosis of a current major depressive episode, however PD was the primary diagnosis. A 120 min PET study of 5-HT(1A)R binding was acquired using a GE Advance scanner in three-dimensional mode. Using quantitative PET image analysis, regional values were obtained for [18F]-FCWAY volume of distribution (DV), corrected for plasma protein binding, and K1, the delivery rate of [18F]-FCWAY from plasma to tissue. MRI scanning was performed using a GE Signa Scanner (3.0 Tesla) to provide an anatomical framework for image analysis and partial volume correction of PET data. PD patients showed lower DV in the anterior cingulate (t = 4.3; p < 0.001), posterior cingulate (t = 4.1; p < 0.001), and raphe (t = 3.1; p = 0.004). Comparing patients with PD, patients with PD and comorbid depression, and healthy controls revealed that DVs did not differ between PD patients and PD patients with comorbid depression, whereas both patient groups differed significantly from controls. These results provide for the first time in vivo evidence for the involvement of 5-HT(1A)Rs in the pathophysiology of PD.

Linear width of the medial temporal lobe can discriminate Alzheimer’s disease from normal aging: the Sunnybrook Dementia Study

To discriminate Alzheimer's disease (AD) from healthy controls, the thinnest medial temporal lobe (tMTL) width on 3D-MRI was measured according to a newly developed method at the inter-collicular sulcus (ICS) level with scans aligned to the long axis of the hippocampus in 22 mild, 27 moderate probable AD patients and 41 healthy controls. For comparison, MTL width replicating the technique of Jobst et al. (jMTL) as well as hippocampal and parahippocampal volumes, were also measured. Using logistic regression taking into account age, sex, and education, tMTL width classified mild AD from controls with a sensitivity of 86%, specificity of 95% and accuracy of 92%. Similar values were obtained for moderate or total AD group versus controls. By comparison, jMTL width was only useful in distinguishing moderate AD from controls, and volumetric measures were equally sensitive in classifying mild and moderate AD in our sample. This quick, reliable, and standardized measurement of tMTL can be helpful in differentiating even mild AD from controls with reasonable accuracy.

Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation

BACKGROUND

Disturbed interpersonal relations and emotional dysregulation are fundamental aspects of borderline personality disorder (BPD). The amygdala plays important roles in modulating vigilance and generating negative emotional states and is often abnormally reactive in disorders of mood and emotion. The aim of this study was to assess amygdala reactivity in BPD patients relative to normal control subjects. We hypothesized that amygdala hyperreactivity contributes to hypervigilance, emotional dysregulation, and disturbed interpersonal relations in BPD.

METHODS

Using functional magnetic resonance imaging, we examined neural responses to 20-sec blocks of neutral, happy, sad, and fearful facial expression (or a fixation point) in 15 BPD and 15 normal control subjects. The DSM IV-diagnosed BPD patients and the normal control subjects were assessed by a clinical research team in a medical school psychiatry department.

RESULTS

Borderline patients showed significantly greater left amygdala activation to the facial expressions of emotion (vs. a fixation point) compared with normal control subjects. Post-scan debriefing revealed that some borderline patients had difficulty disambiguating neutral faces or found them threatening.

CONCLUSIONS

Pictures of human emotional expressions elicit robust differences in amygdala activation levels in borderline patients, compared with normal control subjects, and can be used as probes to study the neuropathophysiologic basis of borderline personality disorder.

Childhood trauma associated with smaller hippocampal volume in women with major depression

OBJECTIVE

Smaller hippocampal volume has been reported only in some but not all studies of unipolar major depressive disorder. Severe stress early in life has also been associated with smaller hippocampal volume and with persistent changes in the hypothalamic-pituitary-adrenal axis. However, prior hippocampal morphometric studies in depressed patients have neither reported nor controlled for a history of early childhood trauma. In this study, the volumes of the hippocampus and of control brain regions were measured in depressed women with and without childhood abuse and in healthy nonabused comparison subjects.

METHOD

Study participants were 32 women with current unipolar major depressive disorder-21 with a history of prepubertal physical and/or sexual abuse and 11 without a history of prepubertal abuse-and 14 healthy nonabused female volunteers. The volumes of the whole hippocampus, temporal lobe, and whole brain were measured on coronal MRI scans by a single rater who was blind to the subjects' diagnoses.

RESULTS

The depressed subjects with childhood abuse had an 18% smaller mean left hippocampal volume than the nonabused depressed subjects and a 15% smaller mean left hippocampal volume than the healthy subjects. Right hippocampal volume was similar across the three groups. The right and left hippocampal volumes in the depressed women without abuse were similar to those in the healthy subjects.

CONCLUSIONS

A smaller hippocampal volume in adult women with major depressive disorder was observed exclusively in those who had a history of severe and prolonged physical and/or sexual abuse in childhood. An unreported history of childhood abuse in depressed subjects could in part explain the inconsistencies in hippocampal volume findings in prior studies in major depressive disorder.

Glucose metabolism in the amygdala in depression: relationship to diagnostic subtype and plasma cortisol levels

In a previous positron emission tomography (PET) study of major depression, we demonstrated that cerebral blood flow was increased in the left amygdala in unipolar depressives with familial pure depressive disease (FPDD) relative to healthy controls [J. Neurosci. 12 (1992) 3628.]. These measures were obtained from relatively low-resolution PET images using a stereotaxic method based upon skull X-ray landmarks. The current experiments aimed to replicate and extend these results using higher-resolution glucose metabolism images and magnetic resonance imaging (MRI)-based region-of-interest (ROI) analysis. The specificity of this finding to FPDD was also investigated by assessing depressed samples with bipolar disorder (BD-D) and depression spectrum disease (DSD). Finally, the relationship between amygdala metabolism and plasma cortisol levels obtained during the scanning procedure was assessed. Glucose metabolism was measured using PET and 18F-fluorodeoxyglucose (18FDG) in healthy control (n=12), FPDD (n=12), DSD (n=9) and BD-D (n=7) samples in the amygdala and the adjacent hippocampus. The left amygdala metabolism differed across groups (P<.001), being increased in both the FPDD and BD-D groups relative to the control group. The left amygdala metabolism was positively correlated with stressed plasma cortisol levels in both the unipolar (r=.69; P<.005) and the bipolar depressives (r=0.68;.1<P<.05). In contrast, neither significant main effects of diagnosis nor significant relationships with plasma cortisol were evident in post hoc analyses of metabolism in the right amygdala or the hippocampus. Preliminary assessment of BD subjects imaged during remission suggested that amygdala metabolism is also elevated in remitted subjects who are not taking mood-stabilizing drugs, but within the normal range in subjects taking mood stabilizers. These data confirm our previous finding that neurophysiological activity is abnormally increased in FPDD, and extend it to BD-D. These abnormalities were not accounted for by spilling in of radioactivity from the adjacent hippocampus. The correlation between left amygdala metabolism and stressed plasma cortisol levels may conceivably reflect either the effect of amygdala activity on corticotropin-releasing hormone (CRH) secretion or the effect of cortisol on amygdala function.

Structural MRI volumetric analysis in patients with organic amnesia, 1: methods and comparative findings across diagnostic groups

BACKGROUND

If they are to be replicable, MRI volume measurements require explicit definitions of structures and of criteria for delineating these structures on MRI. Previously published volumes in healthy subjects show considerable differences in measurements across different studies, including a fourfold variation in estimates of hippocampal volume. Previous neuroimaging reports in patients with Korsakoff syndrome have generally found widespread or non-specific change, whereas in patients with herpes encephalitis the extent of pathological involvement reported beyond the temporal lobes has varied.

METHOD

In the present study, a clear set of anatomical criteria and detailed MRI segmentation procedures were applied to measure whole brain, frontal and temporal lobe, and anterolateral and medial temporal volumes, as well as thalamic areas in patients with organic amnesia (from Korsakoff's syndrome, herpes encephalitis, and focal frontal lesions) as well as healthy controls.

RESULTS

Patients with Korsakoff's syndrome showed decreased thalamic measurements but no significant changes in the medial temporal lobes, whereas patients with herpes encephalitis showed severe medial temporal but not thalamic atrophy. In the patients with known frontal lobe lesions, quantitative analysis on MRI showed reduced frontal lobe volume but no significant temporal lobe or thalamic atrophy.

CONCLUSION

Quantified MRI can be a useful technique with which to examine brain-cognitive relations, provided that detailed techniques are explicitly described. In particular, specific patterns of volume change can be found in vivo in patients with Korsakoff's syndrome and those with herpes encephalitis.

Quantitative magnetic resonance imaging in consecutive patients evaluated for surgical treatment of temporal lobe epilepsy

We present the results of quantitative Magnetic Resonance Imaging (MRI) in 55 consecutively referred patients with clinical evidence of temporal lobe epilepsy (TLE). The Cavalieri method was used in combination with point counting to provide unbiased estimates of the volume of the left and right hippocampus, amygdala, temporal lobe, lateral ventricles and cerebral hemisphere, and pixel by pixel maps of the T2 relaxation time were computed for both central and anterior sections of the hippocampus. The 99th centiles of hippocampal volume, hippocampal volume asymmetry and T2 relaxation times in 20 control subjects provided limits which identified the presence of MTS. The results of the quantitative MRI were compared with the results of conventional diagnostic MRI, foramen ovale (FO) recording and the WADA test. Thirty-one patients were found to have unilateral MTS (17 left and 14 right) and 7 bilateral MTS. No evidence of MTS was detected in 16 patients. Of the 31 patients diagnosed with unilateral MTS on the basis of hippocampal volume and T2 measurement, 74% and 77% would respectively have received the same diagnosis on the basis of hippocampal volume and T2 measurements alone. In comparison to FO recording, quantitative MRI has a sensitivity of 55% and a specificity of 86%, while conventional diagnostic MRI has a sensitivity of 42% and a specificity of 80% for detection of MTS. Unilateral abnormalities were detected by FO recording in 30% cent of patients who appeared normal on quantitative MRI. WADA test results were available for 40 patients. The findings were consistent with quantitative MRI showing reduced memory function ipsilateral to unilateral MTS in 18 patients, but reduced memory function contralateral to unilateral MTS in two patients, and reduced memory function without MR abnormality in seven patients. WADA testing revealed unilateral memory impairments where MRI found bilateral pathology in 4 patients and in 4 patients in whom quantitative MRI detected unilateral MTS there was no evidence of reduced memory during WADA testing of the corresponding cerebral hemisphere. In the patients with unilateral right MTS a highly significant negative correlation (p = 0.0003) was observed between age of onset and the volume of the contralateral temporal lobe. Quantitative MR imaging of the hippocampus (i.e. volume and T2 measurement) is preferable to conventional radiological reporting for providing objective evidence of the presence of MTS on which to base the referral of patients for surgery, and since it has associated morbidity FO recording is now only being used in selected patients. Furthermore, stereology provides a convenient method for estimating the volume of other brain structures, which is relevant to obtaining a better understanding of the effects of laterality and age of onset of TLE.

Evidence of a smaller left hippocampus and left temporal horn in both patients with first episode schizophrenia and normal control subjects

Findings from cerebral magnetic resonance imaging (MRI) studies in schizophrenia indicating temporal lobe involvement have been inconsistent and controversial. In a prospective study, we quantified the volumes of temporal lobe structures in 20 male patients with first episode schizophrenia (FES; mean+/-S.D.=27.4+/-4. 8 years) and 20 healthy age-matched male control subjects (27.7+/-3. 1 years). Measurements were performed on contiguous 2.2-mm coronal MRI slices, which included, as well as the temporal lobe, the amygdala, the hippocampal formation, and the temporal horn of the lateral ventricle. The definition of the borders of the structures relied on measurement guidelines derived from mutual comparisons of MRI and histological data. The definition of the hippocampus-amygdala interface was also validated in a correlated triplanar display. We did not detect any significant volume reductions of the measured structures in the FES group, as compared with healthy control subjects, on either side. Comparisons within groups, however, revealed that in both the patients and the healthy volunteers the hippocampal formations showed a significant right-sided bias (+9%, P=0.004, in the FES group; +12%, P=0.0003 in the control subjects). A significant volume difference in favor of the right hemisphere was also observed in the temporal horns of the lateral ventricles (+17%, P=0.02 in the patients with FES; +34%, P=0. 003, in the control group). There was only a nonsignificant trend for a larger temporal horn on the left side in patients with schizophrenia as compared with the control subjects. Our findings do not indicate a loss or reversal of the normal volume asymmetry pattern in the FES group.

Serotonin type-1A receptor imaging in depression

Regional 5-hydroxytryptamine(1A) (5-HT(1A)) receptor binding potential (BP) of depressed subjects with primary, recurrent, familial mood disorders was compared to that of healthy controls by using positron emission tomography and [carbonyl-(11)C]WAY-100635 ¿[(11)C]N-(2-(4-(2-methoxyphenyl)-1-piperazin-1-yl)ethyl)-N-(2- pyridy l)cyclohexanecarboxamide¿. The mean 5-HT(1A) receptor BP was reduced 42% in the midbrain raphe and 25-33% in limbic and neocortical areas in the mesiotemporal, occipital, and parietal cortex. The magnitude of these abnormalities was most prominent in bipolar depressives and unipolar depressives who had bipolar relatives. These abnormal reductions in 5-HT(1A) receptor BP are consistent with in vivo evidence that 5-HT(1A) receptor sensitivity is reduced in major depressive disorder and postmortem data showing a widespread deficit of 5-HT(1A) receptor expression in primary mood disorders.

Magnetic resonance imaging in temporal lobe epilepsy: usefulness for the etiological diagnosis of temporal lobe epilepsy

With improvement in magnetic resonance (MR) imaging techniques, the ability to identify lesions responsible for temporal lobe epilepsy has increased. MR imaging has also enabled the in vivo diagnosis of hippocampal sclerosis. Brain tumors are responsible for 2-4% of epilepsies in adult population and 10-20% of medically intractable epilepsy. The sensitivity of MR imaging in the diagnosis of tumors and other lesions of the temporal lobe (vascular malformations, etc.) is around 90%. Both hippocampal sclerosis and other temporal lobe lesions are amenable to surgical therapy with excellent postsurgical seizure outcome. In this article, we characterize and underline distinguishing features of the different pathological entities. We also suggest an approach to reviewing the MR images of an epileptic patient.

PET imaging of serotonin 1A receptor binding in depression

BACKGROUND

The serotonin-1A (5HT1A) receptor system has been implicated in the pathophysiology of major depression by postmortem studies of suicide victims and depressed subjects dying of natural causes. This literature is in disagreement, however, regarding the brain regions where 5HT1A receptor binding differs between depressives and controls and the direction of such differences relative to the normal baseline, possibly reflecting the diagnostic heterogeneity inherent within suicide samples. PET imaging using the 5HT1A receptor radioligand, [11C]WAY-100635, may clarify the clinical conditions under which 5HT1A receptor binding potential (BP) is abnormal in depression.

METHODS

Regional 5HT1A receptor BP values were compared between 12 unmedicated depressives with primary, recurrent, familial mood disorders and 8 healthy controls using PET and [carbonyl-11C]WAY-100635. Regions-of-interest (ROI) assessed were the mesiotemporal cortex (hippocampus-amygdala) and midbrain raphe, where previous postmortem studies suggested 5HT1A receptor binding is abnormal in depression.

RESULTS

The mean 5HT1A receptor BP was reduced 41.5% in the raphe (p < .02) and 26.8% in the mesiotemporal cortex (p < .025) in the depressives relative to the controls. Post hoc comparisons showed the abnormal reduction in 5HT1A receptor BP was not limited to these regions, but extended to control ROI in the occipital cortex and postcentral gyrus as well. The magnitude of these abnormalities was most prominent in bipolar depressives (n = 4) and unipolar depressives with bipolar relatives (n = 4).

CONCLUSIONS

Serotonin-1A receptor BP is abnormally decreased in the depressed phase of familial mood disorders in multiple brain regions. Of the regions tested, the magnitude of this reduction was most prominent in the midbrain raphe. Converging evidence from postmortem studies of mood disorders suggests these reductions of 5HT1A receptor BP may be associated with histopathological changes involving the raphe.

The hippocampus: normal anatomy and pathology

The hippocampus is a complex and fascinating region of the brain that has enormous clinical significance. Specifically, small imaging abnormalities may cause major symptoms. We believe that the detection of these lesions will be improved if imaging clinicians have an organized reference that facilitates identification of the cellular zones that comprise the hippocampus.

Memory impairments associated with hippocampal versus parahippocampal-gyrus atrophy: an MR volumetry study in Alzheimer's disease

Delayed memory impairments and medial temporal-lobe atrophy are considered to be cardinal features of Alzheimer's disease (AD). The goal of the present magnetic resonance (MR) volumetry study was to investigate the relationship between both features. We determined MR-derived estimates of hippocampal and parahippocampal volume in a sample of 27 AD patients and in a group of 26 healthy control subjects (NCs) of comparable age and education. We examined the performance of the two groups on immediate and delayed recall trials of an auditory-verbal list-learning task (CVLT), a visual non-verbal memory task (Visual Reproduction of the WMS-R), and a screening procedure that provides an estimate of overall cognitive functioning (DRS). Volumes of the hippocampus and the parahippocampal gyrus were significantly smaller in AD patients than in NCs. AD patients were impaired in their overall level of cognitive functioning and showed memory deficits under immediate and delayed recall conditions. The association between medial temporal-lobe atrophy and cognitive impairments in AD was found to be highly specific: Hippocampal volume correlated positively with delayed but not immediate recall of the verbal auditory list learning task. In contrast, parahippocampal gyrus volume, specifically in the right hemisphere, was positively related to delayed but not immediate recall of the non-verbal visual memory task. In NCs, there was a trend towards a negative association between hippocampal volumes and delayed verbal recall. Our results suggest that hippocampal and parahippocampal gyrus atrophy in AD are related to distinct aspects of the patients' memory impairments. Our findings have implications for current discussions regarding contributions of the hippocampus and the parahippocampal gyrus to memory in the intact human brain.

Human amygdala activation during conditioned fear acquisition and extinction: a mixed-trial fMRI study

Echoplanar functional magnetic resonance imaging (fMRI) was used in normal human subjects to investigate the role of the amygdala in conditioned fear acquisition and extinction. A simple discrimination procedure was employed in which activation to a visual cue predicting shock (CS+) was compared with activation to another cue presented alone (CS-). CS+ and CS- trial types were intermixed in a pseudorandom order. Functional images were acquired with an asymmetric spin echo pulse sequence from three coronal slices centered on the amygdala. Activation of the amygdala/periamygdaloid cortex was observed during conditioned fear acquisition and extinction. The extent of activation during acquisition was significantly correlated with autonomic indices of conditioning in individual subjects. Consistent with a recent electrophysiological recording study in the rat (Quirk et al., 1997), the profile of the amygdala response was temporally graded, although this dynamic was only statistically reliable during extinction. These results provide further evidence for the conservation of amygdala function across species and implicate an amygdalar contribution to both acquisition and extinction processes during associative emotional learning tasks.

Topographic distribution of seizure onset and hippocampal atrophy: relationship between MRI and depth EEG

Medial temporal lobe epilepsy (MTLE) is associated with hippocampal cell loss and organization of the dentate gyrus. Some studies suggest a correlation between the topographic distribution of cell loss and site of epileptogenesis. We studied the relationship between the site of ictal onset with the presence of segmental atrophy in patients with non-lesional MTLE using magnetic resonance imaging (MRI) and depth EEG. Ictal recordings were obtained from 27 patients with longitudinal hippocampal depth electrodes and variable combinations of subdural strips sampling medial temporal structures. The location of the depth electrode contacts was correlated with anatomical landmarks. Seizures were analyzed for the distribution of onset along the long axis of the hippocampus. MRI analysis were performed to detect segmental atrophy. Outcome was assessed 1 year or more following anterior temporal lobectomy. Twenty-five patients had unilateral, and two had bilateral, hippocampal atrophy. One hundred and forty-seven seizures were reviewed: 21 showed focal onset and 126 showed regional onset. Ictal onset involved the amygdala and anterior half of the hippocampus in 80% of the seizures while only 40% of patients had atrophy of these segments. Most patients had excellent outcome. In patients with MTLE the primary area of epileptogenesis does not parallel the hippocampal segments with the greatest degree of volume loss.

Reliability and validity of MRI measurement of the amygdala and hippocampus in children with fragile X syndrome

Evidence from numerous structural magnetic resonance imaging (MRI) studies has converged to implicate mesial temporal lobe structures in the pathophysiology of several developmental and psychiatric disorders. Efforts to integrate the results of these studies are challenged, however, by the lack of consistency, detail and precision in published protocols for the manual measurement of the amygdala and hippocampus. In this study, we describe a highly detailed, standardized protocol for measuring the amygdala and the hippocampus. Within the context of this protocol, we tested the inter- and intra-rater reliability of two frequently cited methods for normalizing the anatomical position of the amygdala and hippocampus prior to measurement. One method consisted of creating a coronal data set in which images are rotated in a plane perpendicular to the long axis of the hippocampus. The second method consisted of creating a coronal data set in which images are rotated in a plane perpendicular to the axis connecting the anterior and posterior commissures. Inter- and intra-rater reliability coefficients (using the intraclass correlation) ranged from 0.80 to 0.98, indicating that both methods for positional normalization are highly reliable. In addition, we tested the validity of each method by comparing the temporal lobe anatomy of children with fragile X syndrome to a group of unaffected children matched by age and gender. We found that hippocampal volumes in children with fragile X were significantly increased when either rotational method was used. These results replicated previous findings, suggesting that either method can be validly applied to neuronanatomic studies of pediatric populations.

Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse--a preliminary report

We have previously reported smaller hippocampal volume and deficits in short-term memory in patients with combat-related posttraumatic stress disorder (PTSD) relative to comparison subjects. The purpose of this study was to compare hippocampal volume in adult survivors of childhood abuse to matched controls. Magnetic resonance imaging was used to measure volume of the hippocampus in adult survivors of childhood abuse (n = 17) and healthy subjects (n = 17) matched on a case-by-case basis for age, sex, race, handedness, years of education, body size, and years of alcohol abuse. All patients met criteria for PTSD secondary to childhood abuse. PTSD patients had a 12% smaller left hippocampal volume relative to the matched controls (p < .05), without smaller volumes of comparison regions (amygdala, caudate, and temporal lobe). The findings were significant after controlling for alcohol, age, and education, with multiple linear regression. These findings suggest that a decrease in left hippocampal volume is associated with abuse-related PTSD.

MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder

OBJECTIVE

Studies in nonhuman primates suggest that high levels of cortisol associated with stress have neurotoxic effects on the hippocampus, a brain structure involved in memory. The authors previously showed that patients with combat-related posttraumatic stress disorder (PTSD) had deficits in short-term memory. The purpose of this study was to compare the hippocampal volume of patients with PTSD to that of subjects without psychiatric disorder.

METHOD

Magnetic resonance imaging was used to measure the volume of the hippocampus in 26 Vietnam combat veterans with PTSD and 22 comparison subjects selected to be similar to the patients in age, sex, race, years of education, socioeconomic status, body size, and years of alcohol abuse.

RESULTS

The PTSD patients had a statistically significant 8% smaller right hippocampal volume relative to that of the comparison subjects, but there was no difference in the volume of other brain regions (caudate and temporal lobe). Deficits in short-term verbal memory as measured with the Wechsler Memory Scale were associated with smaller right hippocampal volume in the PTSD patients only.

CONCLUSIONS

These findings are consistent with a smaller right hippocampal volume in PTSD that is associated with functional deficits in verbal memory.

Hippocampal volume measurements using magnetic resonance imaging in normal young adults

Volumetric analysis of brain magnetic resonance images (MRIs) measures structural changes associated with neurological and neuropsychiatric disorders. Several studies investigated the hippocampus specifically, reporting degrees of atrophy in such disorders. However, the range of normal hippocampal volumes must be known to assess atrophy. In tracings of T1 oblique slice and three-dimensional MRIs in 24 normal subjects reported here, the average volume of right and left hippocampus was 2.90 cm3 and 2.78 cm3, respectively. On paired analysis, this difference was significant. The literature indicated these volumes are in the middle of a wide range of hippocampal volumes (1.73-5.68 cm3) in both MRI-based and histology-based studies. This wide variation can be explained by differing hippocampal boundary definitions; technical factors of image processing, segmentation, and display; sample heterogeneity; and interoperator differences.

Volumes of hippocampus, amygdala and frontal lobes in the MRI-based diagnosis of early Alzheimer's disease: correlation with memory functions

We studied the usefulness of measuring volumes of the hippocampus, amygdala and frontal lobes with coronal magnetic resonance imaging (MRI) scans in the diagnosis of early Alzheimer's disease (AD). We examined 32 patients diagnosed according to the NINCDS-ADRDA criteria of probable AD and 16 age-matched healthy cognitively normal controls. The AD patients had mild dementia with a mean score of 22.8 in the Mini-Mental Status Examination (MMSE). We used a 1.5 T magnetic resonance imager and normalized the volumes for brain area. The AD patients had significantly smaller volumes of the right and the left hippocampus (-38%) (ANOVA, p < 0.0001) and the left frontal lobe (-16%, p < 0.05) compared to controls. The reductions in volumes of the right frontal lobe (-13%), the right amygdala (-14%) or the left amygdala (-18%) were not statistically significant. In the discriminant function analysis which included the volumes of the hippocampus, amygdala, and the frontal lobes and age, the volumes of the left and right hippocampus, the left and right frontal lobe, and the right amygdala entered the model and we could correctly classify 92% of the subjects into AD and control groups (Chi-square 42.6, df 5, p < 0.001). By using the volumes of the hippocampus, the frontal lobes or the amygdala on their alone, the correct classification was achieved in 88%, 65% and 58% of the subjects, respectively. In addition, in AD patients the volumes of the left hippocampus correlated significantly with the MMSE score and with immediate and delayed verbal memory; the smaller the volume the more impaired was their performance. Our data indicate that measurements of volumes of the hippocampus might be useful in diagnosis of early AD.

Correlations between magnetic resonance imaging-based hippocampal sclerosis and depth electrode investigation in epilepsy of the mesiotemporal lobe

Quantitative analysis of hippocampal formations (HF) by magnetic resonance imaging (MRI) was correlated with depth electrode recordings in 18 patients with partial epilepsy. All had seizures of mesiotemporal origin. Electrodes explored three HF segments: amygdala and HF head and anterior and posterior HF body. Corresponding HF measurements were made on coronal MRI sequences, and atrophy was quantified by one global and three segmental indexes of asymmetry per patient. HF from which seizure originated showed global atrophy in 15 patients. Segmental analysis demonstrated discrete tissue damage in 1 patient; thus, 16 patients (88%) had significant hippocampal atrophy ipsilateral to the mesial focus. The existence of more pronounced atrophy in segments giving rise to ictal onset than in segments without ictal onset was not statistically significant. Nevertheless, in posterior HF, all segments (four) with seizure onset were atrophied and none of the nonatrophied posterior segments (four) were at seizure origin. These findings confirm that MRI-detected hippocampal atrophy is a powerful indicator of a mesiotemporal focus and strongly contributes to consideration of resective surgery without intracerebral EEG monitoring. Study of the distribution of maximal tissue damage may add some information, and help surgeons decide on the posterior extent of hippocampus removal. As illustrated by 3 patients who had multiple sites of seizure onset, however, the presence of this marker should not be interpreted systematically as evidence of pure mesiotemporal epilepsy.

Hippocampal formations imaging with axial sections parallel to their longitudinal axis

The complex shape of hippocampal formation (HF) and its obliquity make its morphological analysis difficult using brain imaging techniques. Adapted planes of section are required. The hippocampal axial plane (HAP) parallel to the hippocampus long axis is able to provide a complete and comprehensive view of the structure. HF has a rostrocaudal extent and is divided into three parts, head, body, and tail. Histological sections in the HAP display very well the pattern of the cell layers, with their transversal folding at the head and the tail. At more ventral levels, HF sections consist of parts of the CA1 field and the subicular complex. These are completely embedded in the temporal lobe and separated from its medial surface by the white matter and the cortical plate of the parahippocampal gyrus. More dorsal sections allow the study of the amygdala, uncus and fimbria. Functional images of HF can be accurately defined by combining magnetic resonance imaging (MRI), positron emission tomography (PET), or single photon emission computed tomography (SPECT) in this plane. According to the small dorsal-ventral dimension of the structures, a few slices can cover the whole HF and precise regions of interest may be outlined.

Reliability of in vivo volume measures of hippocampus and other brain structures using MRI

Volume reductions of the hippocampus are associated with Alzheimer's disease, schizophrenia, and epilepsy. We used clinically available MRI methods (2D acquisition; inversion recovery and calculated T2 images; 3 mm contiguous slices) that optimize image contrast, quality, and resolution and standardized positioning protocols to maximize the in vivo accuracy (test-retest reliability) of brain volume measurements in volunteers who were scanned two or three times. Volunteers were scanned in the same MRI instrument (intrascanner reliability) as well as in two different instruments (interscanner reliability). A single rater obtained brain volume measures of seven contiguous slices centered on the anterior commissure. The in vivo intrascanner reliability for measures of anterior hippocampus and ventricular volumes was very good, with reliability coefficients [intraclass r (rxx)] ranging between .855 and .997, and a median coefficient of variation (CV) of 6.4%. Reliability was good for amygdala (rxx of .740 and .764) and for total frontal and temporal lobe volumes and white matter volume measures (rxx ranging between .640 and .823, median coefficient of variation was 3.2%). Overall, interscanner reliability was also good. We discuss the implications of our results relative to the possible clinical utility of hippocampal quantification and the feasibility of prospective studies aimed at quantifying progressive neurodegeneration.

MRI of the temporal lobe: normal variations, with special reference toward epilepsy

Recent investigations of epilepsy, Alzheimer's disease, amnesia, and schizophrenia have used magnetic resonance imaging (MRI) to evaluate changes in temporal lobe structures. Normal variations in these structures need to be defined before one can use these structures to describe abnormal conditions. Twenty-nine normal volunteers were studied by coronal MRI. Frequent findings include notching of the uncus by the tentorium or adjacent vessels (22/29) and asymmetry of the temporal horns (20/29). This finding of uncal notching strengthens the evidence against "incisural sclerosis" as the basis for hippocampal sclerosis. Temporal horn dilatation occurred in four. However, mild asymmetry of the temporal horn was seen frequently at its anterior tip (16/29) and may be related to head rotation. Asymmetry of the choroidal fissure was never marked. Mild asymmetry was common at the hippocampal head (pes). Mild enlargement of the right temporal lobe by visual inspection is not uncommon. Subtle asymmetry of the white matter between the hippocampus and the collateral sulcus occurred in six. The collateral sulcus does not always point to the temporal horn. The occipitotemporal sulcus may point to the temporal horn. Asymmetric uncal protrusion (0/29) and Sylvian fissure dilatation (4/29) occur rarely.

MRI of the normal hippocampus

Before it is possible to use MR imaging to investigate changes in the hippocampus in disease processes such as epilepsy and memory disorders, it is imperative that normal variations are defined. Using specific anatomic locations, we evaluated the hippocampi of 29 normal volunteers with coronal MR studies. Mild variations occur with regard to hippocampal size and shape, and hippocampal fissure visualization. Hippocampal signal intensity is isointense to cortical gray matter. Recognition of normally occurring variations should help prevent over-interpretation of hippocampal changes in pathologic disorders.