Evaluation of MTT Heterogeneity of Perfusion CT Imaging in the Early Brain Injury Phase: An Insight into aSAH Pathopysiology

The concept of early brain injury (EBI) is based on the assumption of a global reduction in brain perfusion following aneurysmal subarachnoid hemorrhage (aSAH). However, the heterogeneity of computed tomography perfusion (CTP) imaging in EBI has not yet been investigated. In contrast, increased mean transit time (MTT) heterogeneity, a possible marker of microvascular perfusion heterogeneity, in the delayed cerebral ischemia (DCI) phase has recently been associated with a poor neurological outcome after aSAH. Therefore, in this study, we investigated whether the heterogeneity of early CTP imaging in the EBI phase is an independent predictor of the neurological outcome after aSAH. We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation (cvMTT) in early CTP scans (within 24 h after ictus) of 124 aSAH patients. Both linear and logistic regression were used to model the mRS outcome, which were treated as numerical and dichotomized values, respectively. Linear regression was used to investigate the linear dependency between the variables. No significant difference in cvMTT between the patients with and those without EVD could be observed (p = 0.69). We found no correlation between cvMTT in early CTP imaging and initial modified Fisher (p = 0.07) and WFNS grades (p = 0.23). The cvMTT in early perfusion imaging did not correlate significantly with the 6-month mRS for the entire study population (p = 0.15) or for any of the subgroups (without EVD: p = 0.21; with EVD: p = 0.3). In conclusion, microvascular perfusion heterogeneity, assessed by the heterogeneity of MTT in early CTP imaging, does not appear to be an independent predictor of the neurological outcome 6 months after aSAH.

The Relation Between Capillary Transit Times and Hemoglobin Saturation Heterogeneity. Part 2: Capillary Networks

Brain metabolism is highly dependent on continuous oxygen supply. Cortical microvascular networks exhibit heterogeneous blood flow, leading to non-uniform tissue oxygenation and capillary hemoglobin saturation. We recently proposed capillary outflow saturation heterogeneity (COSH) to represent effects of heterogeneity on oxygen supply to tissue regions most vulnerable to hypoxia, and showed that diffusive oxygen exchange among red blood cells within capillaries and among capillaries (diffusive interaction) significantly reduces COSH in simplified geometrical configurations. Here, numerical simulations of oxygen transport in capillary network geometries derived from mouse somatosensory cortex are presented. Diffusive interaction was found to reduce COSH by 41 to 62% compared to simulations where diffusive interaction was excluded. Hemoglobin saturation drop across the microvascular network is strongly correlated with red blood cell transit time, but the coefficient of variation of saturation drop is approximately one third lower. Unexpectedly, the radius of the tissue cylinder supplied by a capillary correlates weakly with the anatomical tissue cylinder radius, but strongly with hemoglobin saturation. Thus, diffusive interaction contributes greatly to the microcirculation's ability to achieve tissue oxygenation, despite heterogeneous capillary transit time and hematocrit distribution. These findings provide insight into the effects of cerebral small vessel disease on tissue oxygenation and brain function.

The Relation Between Capillary Transit Times and Hemoglobin Saturation Heterogeneity. Part 1: Theoretical Models

Capillary dysfunction impairs oxygen supply to parenchymal cells and often occurs in Alzheimer's disease, diabetes and aging. Disturbed capillary flow patterns have been shown to limit the efficacy of oxygen extraction and can be quantified using capillary transit time heterogeneity (CTH). However, the transit time of red blood cells (RBCs) through the microvasculature is not a direct measure of their capacity for oxygen delivery. Here we examine the relation between CTH and capillary outflow saturation heterogeneity (COSH), which is the heterogeneity of blood oxygen content at the venous end of capillaries. Models for the evolution of hemoglobin saturation heterogeneity (HSH) in capillary networks were developed and validated using a computational model with moving RBCs. Two representative situations were selected: a Krogh cylinder geometry with heterogeneous hemoglobin saturation (HS) at the inflow, and a parallel array of four capillaries. The heterogeneity of HS after converging capillary bifurcations was found to exponentially decrease with a time scale of 0.15-0.21 s due to diffusive interaction between RBCs. Similarly, the HS difference between parallel capillaries also drops exponentially with a time scale of 0.12-0.19 s. These decay times are substantially smaller than measured RBC transit times and only weakly depend on the distance between microvessels. This work shows that diffusive interaction strongly reduces COSH on a small spatial scale. Therefore, we conclude that CTH influences COSH yet does not determine it. The second part of this study will focus on simulations in microvascular networks from the rodent cerebral cortex. Actual estimates of COSH and CTH will then be given.

The effects of capillary transit time heterogeneity on the BOLD signal

Neurovascular coupling mechanisms give rise to vasodilation and functional hyperemia upon neural activation, thereby altering blood oxygenation. This blood oxygenation level dependent (BOLD) contrast allows studies of activation patterns in the working human brain by functional MRI (fMRI). The BOLD-weighted fMRI signal shows characteristic transients in relation to functional activation, such as the so-called initial dip, overshoot, and post-stimulus undershoot. These transients are modulated by other physiological stimuli and in disease, but the underlying physiological mechanisms remain incompletely understood. Capillary transit time heterogeneity (CTH) has been shown to affect oxygen extraction, and hence blood oxygenation. Here, we examine how recently reported redistributions of capillary blood flow during functional activation would be expected to affect BOLD signal transients. We developed a three-compartment (hemoglobin, plasma, and tissue) model to predict the BOLD signal, incorporating the effects of dynamic changes in CTH. Our model predicts that the BOLD signal represents the superposition of a positive component resulting from increases in cerebral blood flow (CBF), and a negative component, resulting from elevated tissue metabolism and homogenization of capillary flows (reduced CTH). The model reproduces salient features of BOLD signal dynamics under conditions such as hypercapnia, hyperoxia, and caffeine intake, where both brain physiology and BOLD characteristics are altered. Neuroglial signaling and metabolism could affect CBF and capillary flow patterns differently. Further studies of neurovascular and neuro-capillary coupling mechanisms may help us relate BOLD signals to the firing of certain neuronal populations based on their respective BOLD "fingerprints."

The Effects of Capillary Transit Time Heterogeneity (CTH) on the Cerebral Uptake of Glucose and Glucose Analogs: Application to FDG and Comparison to Oxygen Uptake

Glucose is the brain's principal source of ATP, but the extent to which cerebral glucose consumption (CMR_glc) is coupled with its oxygen consumption (CMRO₂) remains unclear. Measurements of the brain's oxygen-glucose index OGI = CMRO₂/CMR_glc suggest that its oxygen uptake largely suffices for oxidative phosphorylation. Nevertheless, during functional activation and in some disease states, brain tissue seemingly produces lactate although cerebral blood flow (CBF) delivers sufficient oxygen, so-called aerobic glycolysis. OGI measurements, in turn, are method-dependent in that estimates based on glucose analog uptake depend on the so-called lumped constant (LC) to arrive at CMR_glc. Capillary transit time heterogeneity (CTH), which is believed to change during functional activation and in some disease states, affects the extraction efficacy of oxygen from blood. We developed a three-compartment model of glucose extraction to examine whether CTH also affects glucose extraction into brain tissue. We then combined this model with our previous model of oxygen extraction to examine whether differential glucose and oxygen extraction might favor non-oxidative glucose metabolism under certain conditions. Our model predicts that glucose uptake is largely unaffected by changes in its plasma concentration, while changes in CBF and CTH affect glucose and oxygen uptake to different extents. Accordingly, functional hyperemia facilitates glucose uptake more than oxygen uptake, favoring aerobic glycolysis during enhanced energy demands. Applying our model to glucose analogs, we observe that LC depends on physiological state, with a risk of overestimating relative increases in CMR_glc during functional activation by as much as 50%.

Brain capillary transit time heterogeneity in healthy volunteers measured by dynamic contrast-enhanced T1 -weighted perfusion MRI

Purpose

Capillary transit time heterogeneity, measured as CTH, may set the upper limit for extraction of substances in brain tissue, e.g., oxygen. The purpose of this study was to investigate the feasibility of dynamic contrast‐enhanced T₁ weighted MRI (DCE‐MRI) at 3 Tesla (T), in estimating CTH based on a gamma‐variate model of the capillary transit time distribution. In addition, we wanted to investigate if a subtle increase of the blood–brain barrier permeability can be incorporated into the model, still allowing estimation of CTH.

Materials and Methods

Twenty‐three healthy subjects were scanned at 3.0T MRI system applying DCE‐MRI and using a gamma‐variate model to estimate CTH as well as cerebral blood flow (CBF), cerebral blood volume (CBV), and permeability of the blood–brain barrier, measured as the influx constant K_i. For proof of principle we also investigated three patients with recent thromboembolic events and a patient with a high grade brain tumor.

Results

In the healthy subjects, we found a narrow symmetric delta‐like capillary transit time distribution in basal ganglia gray matter with median CTH of 0.93 s and interquartile range of 1.33 s. The corresponding residue impulse response function was compatible with the adiabatic tissue homogeneity model. In two patients with complete occlusion of the internal carotid artery and in the patient with a brain tumor CTH was increased with values up to 6 s in the affected brain tissue, with an exponential like residue impulse response function.

Conclusion

Our results open the possibility of characterizing brain perfusion by the capillary transit time distribution using DCE‐MRI, theoretically a determinant of efficient blood to brain transport of important substances.

Level of Evidence: 2

J. MAGN. RESON. IMAGING 2017;45:1809–1820

The effects of capillary transit time heterogeneity (CTH) on brain oxygenation

We recently extended the classic flow-diffusion equation, which relates blood flow to tissue oxygenation, to take capillary transit time heterogeneity (CTH) into account. Realizing that cerebral oxygen availability depends on both cerebral blood flow (CBF) and capillary flow patterns, we have speculated that CTH may be actively regulated and that changes in the capillary morphology and function, as well as in blood rheology, may be involved in the pathogenesis of conditions such as dementia and ischemia-reperfusion injury. The first extended flow-diffusion equation involved simplifying assumptions which may not hold in tissue. Here, we explicitly incorporate the effects of oxygen metabolism on tissue oxygen tension and extraction efficacy, and assess the extent to which the type of capillary transit time distribution affects the overall effects of CTH on flow-metabolism coupling reported earlier. After incorporating tissue oxygen metabolism, our model predicts changes in oxygen consumption and tissue oxygen tension during functional activation in accordance with literature reports. We find that, for large CTH values, a blood flow increase fails to cause significant improvements in oxygen delivery, and can even decrease it; a condition of malignant CTH. These results are found to be largely insensitive to the choice of the transit time distribution.

The effects of transit time heterogeneity on brain oxygenation during rest and functional activation

The interpretation of regional blood flow and blood oxygenation changes during functional activation has evolved from the concept of 'neurovascular coupling', and hence the regulation of arteriolar tone to meet metabolic demands. The efficacy of oxygen extraction was recently shown to depend on the heterogeneity of capillary flow patterns downstream. Existing compartment models of the relation between tissue metabolism, blood flow, and blood oxygenation, however, typically assume homogenous microvascular flow patterns. To take capillary flow heterogeneity into account, we modeled the effect of capillary transit time heterogeneity (CTH) on the 'oxygen conductance' used in compartment models. We show that the incorporation of realistic reductions in CTH during functional hyperemia improves model fits to dynamic blood flow and oxygenation changes acquired during functional activation in a literature animal study. Our results support earlier observations that oxygen diffusion properties seemingly change during various physiologic stimuli, and posit that this phenomenon is related to parallel changes in capillary flow patterns. Furthermore, our results suggest that CTH must be taken into account when inferring brain metabolism from changes in blood flow- or blood oxygenation-based signals .

The role of the microcirculation in delayed cerebral ischemia and chronic degenerative changes after subarachnoid hemorrhage

The mortality after aneurysmal subarachnoid hemorrhage (SAH) is 50%, and most survivors suffer severe functional and cognitive deficits. Half of SAH patients deteriorate 5 to 14 days after the initial bleeding, so-called delayed cerebral ischemia (DCI). Although often attributed to vasospasms, DCI may develop in the absence of angiographic vasospasms, and therapeutic reversal of angiographic vasospasms fails to improve patient outcome. The etiology of chronic neurodegenerative changes after SAH remains poorly understood. Brain oxygenation depends on both cerebral blood flow (CBF) and its microscopic distribution, the so-called capillary transit time heterogeneity (CTH). In theory, increased CTH can therefore lead to tissue hypoxia in the absence of severe CBF reductions, whereas reductions in CBF, paradoxically, improve brain oxygenation if CTH is critically elevated. We review potential sources of elevated CTH after SAH. Pericyte constrictions in relation to the initial ischemic episode and subsequent oxidative stress, nitric oxide depletion during the pericapillary clearance of oxyhemoglobin, vasogenic edema, leukocytosis, and astrocytic endfeet swelling are identified as potential sources of elevated CTH, and hence of metabolic derangement, after SAH. Irreversible changes in capillary morphology and function are predicted to contribute to long-term relative tissue hypoxia, inflammation, and neurodegeneration. We discuss diagnostic and therapeutic implications of these predictions.