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McIlvain G, Magoon EM, Clements RG, Merritt A, Hiscox LV, Schwarb H, Johnson CL. Acute effects of high-intensity exercise on brain mechanical properties and cognitive function. Brain Imaging Behav 2024:10.1007/s11682-024-00873-y. [PMID: 38538876 DOI: 10.1007/s11682-024-00873-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
Previous studies have shown that engagement in even a single session of exercise can improve cognitive performance in the short term. However, the underlying physiological mechanisms contributing to this effect are still being studied. Recently, with improvements to advanced quantitative neuroimaging techniques, brain tissue mechanical properties can be sensitively and noninvasively measured with magnetic resonance elastography (MRE) and regional brain mechanical properties have been shown to reflect individual cognitive performance. Here we assess brain mechanical properties before and immediately after engagement in a high-intensity interval training (HIIT) regimen, as well as one-hour post-exercise. We find that immediately after exercise, subjects in the HIIT group had an average global brain stiffness decrease of 4.2% (p < 0.001), and an average brain damping ratio increase of 3.1% (p = 0.002). In contrast, control participants who did not engage in exercise showed no significant change over time in either stiffness or damping ratio. Changes in brain mechanical properties with exercise appeared to be regionally dependent, with the hippocampus decreasing in stiffness by 10.4%. We also found that one-hour after exercise, brain mechanical properties returned to initial baseline values. The magnitude of changes to brain mechanical properties also correlated with improvements in reaction time on executive control tasks (Eriksen Flanker and Stroop) with exercise. Understanding the neural changes that arise in response to exercise may inform potential mechanisms behind improvements to cognitive performance with acute exercise.
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Affiliation(s)
- Grace McIlvain
- Department of Biomedical Engineering, University of Delaware, Newark, DE, 19716, USA
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Emily M Magoon
- Department of Biomedical Engineering, University of Delaware, Newark, DE, 19716, USA
| | - Rebecca G Clements
- Department of Biomedical Engineering, University of Delaware, Newark, DE, 19716, USA
| | - Alexis Merritt
- Department of Biomedical Engineering, University of Delaware, Newark, DE, 19716, USA
| | - Lucy V Hiscox
- Cardiff University Brain Research Imaging Centre (CUBRIC), Cardiff University, Cardiff, UK
| | - Hillary Schwarb
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Curtis L Johnson
- Department of Biomedical Engineering, University of Delaware, Newark, DE, 19716, USA.
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Milbocker KA, Williams LT, Caban-Rivera DA, Smith IF, Kurtz S, McGarry MDJ, Wattrisse B, Van Houten EEW, Johnson CL, Klintsova AY. Magnetic resonance elastography captures a transient benefit of exercise intervention on forebrain stiffness in a rat model of fetal alcohol spectrum disorders. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:466-477. [PMID: 38225180 PMCID: PMC11162295 DOI: 10.1111/acer.15265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/04/2023] [Accepted: 12/29/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Fetal alcohol spectrum disorders (FASD), a group of prevalent conditions resulting from prenatal alcohol exposure, affect the maturation of cerebral white matter as first identified with neuroimaging. However, traditional methods are unable to track subtle microstructural alterations to white matter. This preliminary study uses a highly sensitive and clinically translatable magnetic resonance elastography (MRE) protocol to assess brain tissue microstructure through its mechanical properties following an exercise intervention in a rat model of FASD. METHODS Female rat pups were either alcohol-exposed (AE) via intragastric intubation of alcohol in milk substitute (5.25 g/kg/day) or sham-intubated (SI) on postnatal days (PD) four through nine to model alcohol exposure during the brain growth spurt. On PD 30, half of AE and SI rats were randomly assigned to either a wheel-running or standard cage for 12 days. Magnetic resonance elastography was used to measure whole brain and callosal mechanical properties at the end of the intervention (around PD 42) and at 1 month post-intervention, and findings were validated with histological quantification of oligoglia. RESULTS Alcohol exposure reduced forebrain stiffness (p = 0.02) in standard-housed rats. The adolescent exercise intervention mitigated this effect, confirming that increased aerobic activity supports proper neurodevelopmental trajectories. Forebrain damping ratio was lowest in standard-housed AE rats (p < 0.01), but this effect was not mitigated by intervention exposure. At 1 month post-intervention, all rats exhibited comparable forebrain stiffness and damping ratio (p > 0.05). Callosal stiffness and damping ratio increased with age. With cessation of exercise, there was a negative rebound effect on the quantity of callosal oligodendrocytes, irrespective of treatment group, which diverged from our MRE results. CONCLUSIONS This is the first application of MRE to measure the brain's mechanical properties in a rodent model of FASD. MRE successfully captured alcohol-related changes in forebrain stiffness and damping ratio. Additionally, MRE identified an exercise-related increase to forebrain stiffness in AE rats.
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Affiliation(s)
- Katrina A. Milbocker
- Department of Psychological & Brain Sciences, University of Delaware, Newark, Delaware, USA
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | - L. Tyler Williams
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | | | - Ian F. Smith
- Department of Psychological & Brain Sciences, University of Delaware, Newark, Delaware, USA
| | - Samuel Kurtz
- Laboratorie de Mecanique et Genie Civil, CNRS, Universite de Montpellier, Montpellier, France
| | | | - Bertrand Wattrisse
- Laboratorie de Mecanique et Genie Civil, CNRS, Universite de Montpellier, Montpellier, France
| | | | - Curtis L. Johnson
- Department of Psychological & Brain Sciences, University of Delaware, Newark, Delaware, USA
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | - Anna Y. Klintsova
- Department of Psychological & Brain Sciences, University of Delaware, Newark, Delaware, USA
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Pavuluri K, Huston J, Ehman RL, Manduca A, Jack CR, Senjem ML, Vemuri P, Murphy MC. Associations between vascular health, brain stiffness and global cognitive function. Brain Commun 2024; 6:fcae073. [PMID: 38505229 PMCID: PMC10950054 DOI: 10.1093/braincomms/fcae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/19/2023] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Vascular brain injury results in loss of structural and functional connectivity and leads to cognitive impairment. Its various manifestations, including microinfarcts, microhaemorrhages and white matter hyperintensities, result in microstructural tissue integrity loss and secondary neurodegeneration. Among these, tissue microstructural alteration is a relatively early event compared with atrophy along the aging and neurodegeneration continuum. Understanding its association with cognition may provide the opportunity to further elucidate the relationship between vascular health and clinical outcomes. Magnetic resonance elastography offers a non-invasive approach to evaluate tissue mechanical properties, providing a window into the microstructural integrity of the brain. This retrospective study evaluated brain stiffness as a potential biomarker for vascular brain injury and its role in mediating the impact of vascular dysfunction on cognitive impairment. Seventy-five participants from the Mayo Clinic Study of Aging underwent brain imaging using a 3T MR imager with a spin-echo echo-planar imaging sequence for magnetic resonance elastography and T1- and T2-weighted pulse sequences. This study evaluated the effects of vascular biomarkers (white matter hyperintensities and cardiometabolic condition score) on brain stiffness using voxelwise analysis. Partial correlation analysis explored associations between brain stiffness, white matter hyperintensities, cardiometabolic condition and global cognition. Mediation analysis determined the role of stiffness in mediating the relationship between vascular biomarkers and cognitive performance. Statistical significance was set at P-values < 0.05. Diagnostic accuracy of magnetic resonance elastography stiffness for white matter hyperintensities and cardiometabolic condition was evaluated using receiver operator characteristic curves. Voxelwise linear regression analysis indicated white matter hyperintensities negatively correlate with brain stiffness, specifically in periventricular regions with high white matter hyperintensity levels. A negative association between cardiovascular risk factors and stiffness was also observed across the brain. No significant patterns of stiffness changes were associated with amyloid load. Global stiffness (µ) negatively correlated with both white matter hyperintensities and cardiometabolic condition when all other covariables including amyloid load were controlled. The positive correlation between white matter hyperintensities and cardiometabolic condition weakened and became statistically insignificant when controlling for other covariables. Brain stiffness and global cognition were positively correlated, maintaining statistical significance after adjusting for all covariables. These findings suggest mechanical alterations are associated with cognitive dysfunction and vascular brain injury. Brain stiffness significantly mediated the indirect effects of white matter hyperintensities and cardiometabolic condition on global cognition. Local cerebrovascular diseases (assessed by white matter hyperintensities) and systemic vascular risk factors (assessed by cardiometabolic condition) impact brain stiffness with spatially and statistically distinct effects. Global brain stiffness is a significant mediator between vascular disease measures and cognitive function, highlighting the value of magnetic resonance elastography-based mechanical assessments in understanding this relationship.
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Affiliation(s)
| | - John Huston
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Armando Manduca
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Clifford R Jack
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew L Senjem
- Department of Information Technology, Mayo Clinic, Rochester, MN 55905, USA
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Feng Y, Murphy MC, Hojo E, Li F, Roberts N. Magnetic Resonance Elastography in the Study of Neurodegenerative Diseases. J Magn Reson Imaging 2024; 59:82-96. [PMID: 37084171 DOI: 10.1002/jmri.28747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/22/2023] Open
Abstract
Neurodegenerative diseases such as Alzheimer's disease (AD) and Parkinson's disease (PD) present a major health burden to society. Changes in brain structure and cognition are generally only observed at the late stage of the disease. Although advanced magnetic resonance imaging (MRI) techniques such as diffusion imaging may allow identification of biomarkers at earlier stages of neurodegeneration, early diagnosis is still challenging. Magnetic resonance elastography (MRE) is a noninvasive MRI technique for studying the mechanical properties of tissues by measuring the wave propagation induced in the tissues using a purpose-built actuator. Here, we present a systematic review of preclinical and clinical studies in which MRE has been applied to study neurodegenerative diseases. Actuator systems for data acquisition, inversion algorithms for data analysis, and sample demographics are described and tissue stiffness measures obtained for the whole brain and internal structures are summarized. A total of six animal studies and eight human studies have been published. The animal studies refer to 123 experimental animals (68 AD and 55 PD) and 121 wild-type animals, while the human studies refer to 142 patients with neurodegenerative disease (including 56 AD and 17 PD) and 166 controls. The animal studies are consistent in the reporting of decreased stiffness of the hippocampal region in AD mice. However, in terms of disease progression, although consistent decreases in either storage modulus or shear modulus magnitude are reported for whole brain, there is variation in the results reported for the hippocampal region. The clinical studies are consistent in reports of a significant decrease in either whole brain storage modulus or shear modulus magnitude, in both AD and PD and with different brain structures affected in different neurodegenerative diseases. MRE studies of neurodegenerative diseases are still in their infancy, and in future it will be interesting to investigate potential relationships between brain mechanical properties and clinical measures, which may help elucidate the mechanisms underlying onset and progression of neurodegenerative diseases. EVIDENCE LEVEL: 1. TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Yuan Feng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Department of Radiology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Institute of Medical Robotics, Shanghai Jiao Tong University, Shanghai, China
- National Engineering Research Center of Advanced Magnetic Resonance Technologies for Diagnosis and Therapy (NERC-AMRT), Shanghai Jiao Tong University, Shanghai, China
| | - Matthew C Murphy
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Emi Hojo
- Centre for Reproductive Health (CRH), School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Fei Li
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Neil Roberts
- Centre for Reproductive Health (CRH), School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
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Sanjana F, Delgorio PL, DeConne TM, Hiscox LV, Pohlig RT, Johnson CL, Martens CR. Vascular determinants of hippocampal viscoelastic properties in healthy adults across the lifespan. J Cereb Blood Flow Metab 2023; 43:1931-1941. [PMID: 37395479 PMCID: PMC10676145 DOI: 10.1177/0271678x231186571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
Arterial stiffness and cerebrovascular pulsatility are non-traditional risk factors of Alzheimer's disease. However, there is a gap in understanding the earliest mechanisms that link these vascular determinants to brain aging. Changes to mechanical tissue properties of the hippocampus (HC), a brain structure essential for memory encoding, may reflect the impact of vascular dysfunction on brain aging. We tested the hypothesis that arterial stiffness and cerebrovascular pulsatility are related to HC tissue properties in healthy adults across the lifespan. Twenty-five adults underwent measurements of brachial blood pressure (BP), large elastic artery stiffness, middle cerebral artery pulsatility index (MCAv PI), and magnetic resonance elastography (MRE), a sensitive measure of HC viscoelasticity. Individuals with higher carotid pulse pressure (PP) exhibited lower HC stiffness (β = -0.39, r = -0.41, p = 0.05), independent of age and sex. Collectively, carotid PP and MCAv PI significantly explained a large portion of the total variance in HC stiffness (adjusted R2 = 0.41, p = 0.005) in the absence of associations with HC volumes. These cross-sectional findings suggest that the earliest reductions in HC tissue properties are associated with alterations in vascular function.
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Affiliation(s)
- Faria Sanjana
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Peyton L Delgorio
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
| | - Theodore M DeConne
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Lucy V Hiscox
- Cardiff University Brain Research Imaging Centre (CUBRIC), Cardiff University, Cardiff, UK
| | - Ryan T Pohlig
- Department of Epidemiology, University of Delaware, Newark, DE, USA
| | - Curtis L Johnson
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
| | - Christopher R Martens
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
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Milbocker KA, Williams LT, Caban-Rivera DA, Smith IF, Kurtz S, McGarry MDJ, Wattrisse B, Van Houten EEW, Johnson CL, Klintsova AY. Monitoring lasting changes to brain tissue integrity through mechanical properties following adolescent exercise intervention in a rat model of Fetal Alcohol Spectrum Disorders. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.26.559571. [PMID: 37808633 PMCID: PMC10557734 DOI: 10.1101/2023.09.26.559571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Fetal Alcohol Spectrum Disorders (FASD) encompass a group of highly prevalent conditions resulting from prenatal alcohol exposure. Alcohol exposure during the third trimester of pregnancy overlapping with the brain growth spurt is detrimental to white matter growth and myelination, particularly in the corpus callosum, ultimately affecting tissue integrity in adolescence. Traditional neuroimaging techniques have been essential for assessing neurodevelopment in affected youth; however, these methods are limited in their capacity to track subtle microstructural alterations to white matter, thus restricting their effectiveness in monitoring therapeutic intervention. In this preliminary study we use a highly sensitive and clinically translatable Magnetic Resonance Elastography (MRE) protocol for assessing brain tissue microstructure through its mechanical properties following an exercise intervention in a rat model of FASD. Methods Rat pups were divided into two groups: alcohol-exposed (AE) pups which received alcohol in milk substitute (5.25 g/kg/day) via intragastric intubation on postnatal days (PD) four through nine during the rat brain growth spurt (Dobbing and Sands, 1979), or sham-intubated (SI) controls. In adolescence, on PD 30, half AE and SI rats were randomly assigned to either a modified home cage with free access to a running wheel or to a new home cage for 12 days (Gursky and Klintsova, 2017). Previous studies conducted in the lab have shown that 12 days of voluntary exercise intervention in adolescence immediately ameliorated callosal myelination in AE rats (Milbocker et al., 2022, 2023). MRE was used to measure longitudinal changes to mechanical properties of the whole brain and the corpus callosum at intervention termination and one-month post-intervention. Histological quantification of precursor and myelinating oligoglia in corpus callosum was performed one-month post-intervention. Results Prior to intervention, AE rats had lower forebrain stiffness in adolescence compared to SI controls ( p = 0.02). Exercise intervention immediately mitigated this effect in AE rats, resulting in higher forebrain stiffness post-intervention in adolescence. Similarly, we discovered that forebrain damping ratio was lowest in AE rats in adolescence ( p < 0.01), irrespective of intervention exposure. One-month post-intervention in adulthood, AE and SI rats exhibited comparable forebrain stiffness and damping ratio (p > 0.05). Taken together, these MRE data suggest that adolescent exercise intervention supports neurodevelopmental "catch-up" in AE rats. Analysis of the stiffness and damping ratio of the body of corpus callosum revealed that these measures increased with age. Finally, histological quantification of myelinating oligodendrocytes one-month post-intervention revealed a negative rebound effect of exercise cessation on the total estimate of these cells in the body of corpus callosum, irrespective of treatment group which was not convergent with noninvasive MRE measures. Conclusions This is the first application of MRE to measure changes in brain mechanical properties in a rodent model of FASD. MRE successfully captured alcohol-related changes to forebrain stiffness and damping ratio in adolescence. These preliminary findings expand upon results from previous studies which used traditional diffusion neuroimaging to identify structural changes to the adolescent brain in rodent models of FASD (Milbocker et al., 2022; Newville et al., 2017). Additionally, in vivo MRE identified an exercise-related alteration to forebrain stiffness that occurred in adolescence, immediately post-intervention.
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Clements RG, Claros-Olivares CC, McIlvain G, Brockmeier AJ, Johnson CL. Mechanical Property Based Brain Age Prediction using Convolutional Neural Networks. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.12.528186. [PMID: 36824781 PMCID: PMC9948973 DOI: 10.1101/2023.02.12.528186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Brain age is a quantitative estimate to explain an individual's structural and functional brain measurements relative to the overall population and is particularly valuable in describing differences related to developmental or neurodegenerative pathology. Accurately inferring brain age from brain imaging data requires sophisticated models that capture the underlying age-related brain changes. Magnetic resonance elastography (MRE) is a phase contrast MRI technology that uses external palpations to measure brain mechanical properties. Mechanical property measures of viscoelastic shear stiffness and damping ratio have been found to change across the entire life span and to reflect brain health due to neurodegenerative diseases and even individual differences in cognitive function. Here we develop and train a multi-modal 3D convolutional neural network (CNN) to model the relationship between age and whole brain mechanical properties. After training, the network maps the measurements and other inputs to a brain age prediction. We found high performance using the 3D maps of various mechanical properties to predict brain age. Stiffness maps alone were able to predict ages of the test group subjects with a mean absolute error (MAE) of 3.76 years, which is comparable to single inputs of damping ratio (MAE: 3.82) and outperforms single input of volume (MAE: 4.60). Combining stiffness and volume in a multimodal approach performed the best, with an MAE of 3.60 years, whereas including damping ratio worsened model performance. Our results reflect previous MRE literature that had demonstrated that stiffness is more strongly related to chronological age than damping ratio. This machine learning model provides the first prediction of brain age from brain biomechanical data-an advancement towards sensitively describing brain integrity differences in individuals with neuropathology.
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Hiscox LV, Fairchild G, Donald KA, Groenewold NA, Koen N, Roos A, Narr KL, Lawrence M, Hoffman N, Wedderburn CJ, Barnett W, Zar HJ, Stein DJ, Halligan SL. Antenatal maternal intimate partner violence exposure is associated with sex-specific alterations in brain structure among young infants: Evidence from a South African birth cohort. Dev Cogn Neurosci 2023; 60:101210. [PMID: 36764039 PMCID: PMC9929680 DOI: 10.1016/j.dcn.2023.101210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023] Open
Abstract
Maternal psychological distress during pregnancy has been linked to adverse outcomes in children with evidence of sex-specific effects on brain development. Here, we investigated whether in utero exposure to intimate partner violence (IPV), a particularly severe maternal stressor, is associated with brain structure in young infants from a South African birth cohort. Exposure to IPV during pregnancy was measured in 143 mothers at 28-32 weeks' gestation and infants underwent structural and diffusion magnetic resonance imaging (mean age 3 weeks). Subcortical volumetric estimates were compared between IPV-exposed (n = 63; 52% female) and unexposed infants (n = 80; 48% female), with white matter microstructure also examined in a subsample (IPV-exposed, n = 28, 54% female; unexposed infants, n = 42, 40% female). In confound adjusted analyses, maternal IPV exposure was associated with sexually dimorphic effects in brain volumes: IPV exposure predicted a larger caudate nucleus among males but not females, and smaller amygdala among females but not males. Diffusivity alterations within white matter tracts of interest were evident in males, but not females exposed to IPV. Results were robust to the removal of mother-infant pairs with pregnancy complications. Further research is required to understand how these early alterations are linked to the sex-bias in neuropsychiatric outcomes later observed in IPV-exposed children.
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Affiliation(s)
- Lucy V Hiscox
- Department of Psychology, University of Bath, Bath, UK.
| | | | - Kirsten A Donald
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa; The Neuroscience institute, University of Cape Town, Cape Town, South Africa
| | - Nynke A Groenewold
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa; The Neuroscience institute, University of Cape Town, Cape Town, South Africa; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Nastassja Koen
- The Neuroscience institute, University of Cape Town, Cape Town, South Africa; SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Annerine Roos
- The Neuroscience institute, University of Cape Town, Cape Town, South Africa; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Katherine L Narr
- Departments of Neurology, Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Marina Lawrence
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Nadia Hoffman
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Catherine J Wedderburn
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa; The Neuroscience institute, University of Cape Town, Cape Town, South Africa; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Whitney Barnett
- Department of Psychology and Human Development, Vanderbilt University, USA
| | - Heather J Zar
- Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa; SA MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- The Neuroscience institute, University of Cape Town, Cape Town, South Africa; SA MRC Unit on Risk & Resilience in Mental Disorders, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Sarah L Halligan
- Department of Psychology, University of Bath, Bath, UK; Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
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