Efficacy and Safety of Cilostazol in Mild Cognitive Impairment: A Randomized Clinical Trial

Importance

Recent evidence indicates the efficacy of β-amyloid immunotherapy for the treatment of Alzheimer disease, highlighting the need to promote β-amyloid removal from the brain. Cilostazol, a selective type 3 phosphodiesterase inhibitor, promotes such clearance by facilitating intramural periarterial drainage.

Objective

To determine the safety and efficacy of cilostazol in mild cognitive impairment.

Design, Setting, and Participants

The COMCID trial (A Trial of Cilostazol for Prevention of Conversion from Mild Cognitive Impairment to Dementia) was an investigator-initiated, double-blind, phase 2 randomized clinical trial. Adult participants were registered between May 25, 2015, and March 31, 2018, and received placebo or cilostazol for up to 96 weeks. Participants were treated in the National Cerebral and Cardiovascular Center and 14 other regional core hospitals in Japan. Patients with mild cognitive impairment with Mini-Mental State Examination (MMSE) scores of 22 to 28 points (on a scale of 0 to 30, with lower scores indicating greater cognitive impairment) and Clinical Dementia Rating scores of 0.5 points (on a scale of 0, 0.5, 1, 2, and 3, with higher scores indicating more severe dementia) were enrolled. The data were analyzed from May 1, 2020, to December 1, 2020.

Interventions

The participants were treated with placebo, 1 tablet twice daily, or cilostazol, 50 mg twice daily, for up to 96 weeks.

Main Outcomes and Measures

The primary end point was the change in the total MMSE score from baseline to the final observation. Safety analyses included all adverse events.

Results

The full analysis set included 159 patients (66 [41.5%] male; mean [SD] age, 75.6 [5.2] years) who received placebo or cilostazol at least once. There was no statistically significant difference between the placebo and cilostazol groups for the primary outcome. The least-squares mean (SE) changes in the MMSE scores among patients receiving placebo were -0.1 (0.3) at the 24-week visit, -0.8 (0.3) at 48 weeks, -1.2 (0.4) at 72 weeks, and -1.3 (0.4) at 96 weeks. Among those receiving cilostazol, the least-squares mean (SE) changes in MMSE scores were -0.6 (0.3) at 24 weeks, -1.0 (0.3) at 48 weeks, -1.1 (0.4) at 72 weeks, and -1.8 (0.4) at 96 weeks. Two patients (2.5%) in the placebo group and 3 patients (3.8%) in the cilostazol group withdrew owing to adverse effects. There was 1 case of subdural hematoma in the cilostazol group, which may have been related to the cilostazol treatment; the patient was successfully treated surgically.

Conclusions and Relevance

In this randomized clinical trial, cilostazol was well tolerated, although it did not prevent cognitive decline. The efficacy of cilostazol should be tested in future trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT02491268.

Voxel-based clustered imaging by multiparameter diffusion tensor images for predicting the grade and proliferative activity of meningioma

INTRODUCTION

Meningiomas are the most common primary central nervous system tumors. Predicting the grade and proliferative activity of meningiomas would influence therapeutic strategies. We aimed to apply the multiple parameters from preoperative diffusion tensor images for predicting meningioma grade and proliferative activity.

METHODS

Nineteen patients with low-grade meningiomas and eight with high-grade meningiomas were included. For the prediction of proliferative activity, the patients were divided into two groups: Ki-67 monoclonal antibody labeling index (MIB-1 LI) < 5% (lower MIB-1 LI group; n = 18) and MIB-1 LI ≥ 5% (higher MIB-1 LI group; n = 9). Six features, diffusion-weighted imaging, fractional anisotropy, mean, axial, and radial diffusivities, and raw T2 signal with no diffusion weighting, were extracted as multiple parameters from diffusion tensor imaging. The two-level clustering approach for a self-organizing map followed by the K-means algorithm was applied to cluster a large number of input vectors with the six features. We also validated whether the diffusion tensor-based clustered image (DTcI) was helpful for predicting preoperative meningioma grade or proliferative activity.

RESULTS

The sensitivity, specificity, accuracy, and area under the curve of receiver operating characteristic curves from the 16-class DTcIs for differentiating high- and low-grade meningiomas were 0.870, 0.901, 0.891, and 0.959, and those from the 10-class DTcIs for differentiating higher and lower MIB-1 LIs were 0.508, 0.770, 0.683, and 0.694, respectively. The log-ratio values of class numbers 13, 14, 15, and 16 were significantly higher in high-grade meningiomas than in low-grade meningiomas (p < .001). With regard to MIB-1 LIs, the log-ratio values of class numbers 8, 9, and 10 were higher in meningiomas with higher MIB-1 groups (p < .05).

CONCLUSION

The multiple diffusion tensor imaging-based parameters from the voxel-based DTcIs can help differentiate between low- and high-grade meningiomas and between lower and higher proliferative activities.

People with High Empathy Show Increased Cortical Activity around the Left Medial Parieto-Occipital Sulcus after Watching Social Interaction of On-Screen Characters

People with high empathy interpret others’ mental states in daily social interactions. To investigate their characteristics of social cognitive processing, we compared neuromagnetic activities between 20 males with high empathy and 23 males with low empathy while watching social interactions between two characters. Twenty stories of four-panel comic strips were presented; the first three panels described social interactions, and the last panel described empathic/nonempathic behaviors. People with high empathy exhibited increased cortical activity in the right occipital region, medial part of the bilateral superior frontal gyri, and right posterior insula while watching social interaction scenes, which suggests that they paid attention to others’ faces and bodies, and inferred others’ mental states. They also exhibited increased cortical activity in the left superior frontal gyrus while watching empathic behaviors. Moreover, they exhibited increased cortical activity in the region around the left medial parieto-occipital sulcus, which is related to self-projection, while passively watching both empathic and nonempathic endings. Taken together, these results suggest that people with high empathy pay attention to others and actively infer others’ mental states while watching social interactions and that they reconstruct others’ mental states and intentions through self-projection after watching a sequence of others’ behaviors.

Salient Properties in Bimanual Haptic Volume Perception: Influence of Object Shape, Finger Pair, and Schizotypal Personality Traits

Bimanual haptic volume perception refers to somatosensory access to volume information through both hands, and the characteristics that influence this perception remain unclear. This article investigated the influence of target object shapes and finger pairs on bimanual haptic perception; in addition, associations of bimanual haptic impairment and schizotypal features in nonpsychotic individuals were investigated. Twenty blindfolded participants bimanually discriminated volume variations in regular solid objects under different shape (tetrahedron, cube, or sphere) and finger pair (high- or low-sensitivity pairs) conditions using a newly developed bimanual haptic volume presentation device. Discrimination thresholds were then associated with schizotypal traits using the Chinese version of the Schizotypal Personality Questionnaire. Target object shape and finger pairs significantly influenced bimanual haptic volume perception. Volume discrimination thresholds were significantly higher with the tetrahedron stimuli than the cubic or spherical stimuli in high-sensitivity pair conditions, but no significant differences among shapes were found in low-sensitivity pair conditions. Moreover, volume discrimination thresholds with high-sensitivity pairs were correlated with the paranoid score of the schizotypal personality questionnaire. The findings provide initial evidence toward understanding the nature of bimanual haptic volume perception, including the properties of objects, individuals, and object-individual interfaces.

Optimal Model Mapping for Intravoxel Incoherent Motion MRI

In general, only one diffusion model would be applied to whole field-of-view voxels in the intravoxel incoherent motion-magnetic resonance imaging (IVIM-MRI) study. However, the choice of the applied diffusion model can significantly influence the estimated diffusion parameters. The quality of the diffusion analysis can influence the reliability of the perfusion analysis. This study proposed an optimal model mapping method to improve the reliability of the perfusion parameter estimation in the IVIM study. Six healthy volunteers (five males and one female; average age of 38.3 ± 7.5 years). Volunteers were examined using a 3.0 Tesla scanner. IVIM-MRI of the brain was applied at 17 b-values ranging from 0 to 2,500 s/mm². The Gaussian model, the Kurtosis model, and the Gamma model were found to be optimal for the CSF, white matter (WM), and gray matter (GM), respectively. In the mean perfusion fraction (f_p) analysis, the GM/WM ratios were 1.16 (Gaussian model), 1.80 (Kurtosis model), 1.94 (Gamma model), and 1.54 (Optimal model mapping); in the mean pseudo diffusion coefficient (D^*) analysis, the GM/WM ratios were 1.18 (Gaussian model), 1.19 (Kurtosis model), 1.56 (Gamma model), and 1.24 (Optimal model mapping). With the optimal model mapping method, the estimated f_p and D^* were reliable compared with the conventional methods. In addition, the optimal model maps, the associated products of this method, may provide additional information for clinical diagnosis.

A venous mechanism of ventriculomegaly shared between traumatic brain injury and normal ageing

Recently, age-related timing dissociation between the superficial and deep venous systems has been observed; this was particularly pronounced in patients with normal pressure hydrocephalus, suggesting a common mechanism of ventriculomegaly. Establishing the relationship between venous drainage and ventricular enlargement would be clinically relevant and could provide insight into the mechanisms underlying brain ageing. To investigate a possible link between venous drainage and ventriculomegaly in both normal ageing and pathological conditions, we compared 225 healthy subjects (137 males and 88 females) and 71 traumatic brain injury patients of varying ages (53 males and 18 females) using MRI-based volumetry and a novel perfusion-timing analysis. Volumetry, focusing on the CSF space, revealed that the sulcal space and ventricular size presented different lifespan profiles with age; the latter presented a quadratic, rather than linear, pattern of increase. The venous timing shift slightly preceded this change, supporting a role for venous drainage in ventriculomegaly. In traumatic brain injury, a small but significant disease effect, similar to idiopathic normal pressure hydrocephalus, was found in venous timing, but it tended to decrease with age at injury, suggesting an overlapping mechanism with normal ageing. Structural bias due to, or a direct causative role of ventriculomegaly was unlikely to play a dominant role, because of the low correlation between venous timing and ventricular size after adjustment for age in both patients and controls. Since post-traumatic hydrocephalus can be asymptomatic and occasionally overlooked, the observation suggested a link between venous drainage and CSF accumulation. Thus, hydrocephalus, involving venous insufficiency, may be a part of normal ageing, can be detected non-invasively, and is potentially treatable. Further investigation into the clinical application of this new marker of venous function is therefore warranted.

A Nationwide Survey and Multicenter Registry-Based Database of Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy in Japan

Objectives

Clinical characteristics of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) include migraine, recurrent stroke, white matter lesions, and vascular dementia. CADASIL is one of the most common hereditary cerebral small vessel diseases. Clinical presentation of CADASIL varies and a racial gap may exist between the Asian and Caucasian populations. This is the first nationwide epidemiological survey which aimed to elucidate the clinical features of CADASIL in Japan. Moreover, the registration database of CADASIL was constructed.

Methods

Subjects included CADASIL patients who visited the hospitals (totally 1,448 hospitals) certified by the Japanese Society of Neurology and/or Japan Stroke Society in 2016. This study consisted of a two-step survey; patients with CADASIL were identified genetically by the first questionnaire, and their clinical features were assessed by the second questionnaire. Selected 6 hospitals registered the data of all CADASIL patients using a Research Electronic Data Capture (REDCap) system for the second questionnaire.

Results

Based on the criteria, 88 patients (50 male and 38 female) with CADASIL were enrolled. The mean age of symptom onset was 49.5 years. Sixteen (18.2%) patients had an elderly onset (>60 years). Thirteen patients (13.6%) had history of migraine with aura and 33 patients (37.5%) had vascular risk factor(s). From among the 86 patients who were examined using magnetic resonance imaging, abnormal deep white matter lesions were detected in 85 patients (98.8%), WMLs extending to anterior temporal pole in 73 patients (84.9%), and cerebral microbleeds in 41 patients (47.7%). Anti-platelet therapy was received by 65 patients (73.9%). Thirty-eight patients (43.2%) underwent treatment with lomerizine hydrochloride. Thirty-four different mutations of NOTCH3 were found in exons 2, 3, 4, 5, 6, 8, 11, 14, and 19. Most of the mutations existed in exon 4 (n = 44, 60.3%). The prevalence rate of CADASIL was 1.20 to 3.58 per 100,000 adults in Japan.

Conclusion

This questionnaire-based study revealed clinical features and treatment status in Japanese CADASIL patient, although it may not be an exhaustive search. We have constructed the REDCap database for these CADASIL patients.

Comparison of Phase Synchronization Measures for Identifying Stimulus-Induced Functional Connectivity in Human Magnetoencephalographic and Simulated Data

Phase synchronization measures are widely used for investigating inter-regional functional connectivity (FC) of brain oscillations, but which phase synchronization measure should be chosen for a given experiment remains unclear. Using neuromagnetic brain signals recorded from healthy participants during somatosensory stimuli, we compared the performance of four phase synchronization measures, imaginary part of phase-locking value, imaginary part of coherency (ImCoh), phase lag index and weighted phase lag index (wPLI), for detecting stimulus-induced FCs between the contralateral primary and ipsilateral secondary somatosensory cortices. The analyses revealed that ImCoh exhibited the best performance for detecting stimulus-induced FCs, followed by the wPLI. We found that amplitude weighting, which is related to computing both ImCoh and wPLI, effectively attenuated the influence of noise contamination. A simulation study modeling noise-contaminated periodograms replicated these findings. The present results suggest that the amplitude-dependent measures, ImCoh followed by wPLI, may have the advantage in detecting stimulus-induced FCs.

Resting-state Functional Magnetic Resonance Imaging Identifies Cerebrovascular Reactivity Impairment in Patients With Arterial Occlusive Diseases: A Pilot Study

BACKGROUND

The development of noninvasive approaches for identifying hypoperfused brain tissue at risk is of major interest. Recently, the temporal-shift (TS) maps estimated from resting-state blood oxygenation level-dependent (BOLD) signals have been proposed for determining hemodynamic state.

OBJECTIVE

To examine the equivalency of the TS map and the cerebrovascular reactivity (CVR) map derived from acetazolamide-challenged single-photon emission computed tomography (SPECT) in identifying hemodynamic impairment in patients with arterial occlusive diseases.

METHODS

Twenty-three patients with arterial occlusive diseases who underwent SPECT were studied. With a recursive TS analysis of low-frequency fluctuation of the BOLD signal, a TS map relative to the global signal was created for each patient. The voxel-by-voxel correlation coefficient was calculated to examine the image similarity between TS and SPECT-based cerebral blood flow (CBF) or CVR maps in each patient. Furthermore, simple linear regression analyses were performed to examine the quantitative relationship between the TS of BOLD signals and CVR in each cerebrovascular territory.

RESULTS

The within-patient, voxel-by-voxel comparison revealed that the TS map was more closely correlated with SPECT-CVR map ([Z(r)] = 0.42 ± 0.18) than SPECT-CBF map ([Z(r)] = 0.058 ± 0.11; P < .001, paired t-test). The regression analysis showed a significant linear association between the TS of BOLD signals and CVR in the anterior circulation where the reduction of CVR was evident in the patient group.

CONCLUSION

BOLD TS analysis has potential as a noninvasive alternative to current methods based on CVR for identification of tissue at risk of ischemic stroke.

Tactile Angle Discrimination Decreases due to Subjective Cognitive Decline in Alzheimer's Disease

BACKGROUND

Subjective Cognitive Decline (SCD) is the early preclinical stage of Alzheimer's Disease (AD). Previous study provided an invaluable contribution by showing that a tactile angle discrimination system can be used to distinguish between healthy older individuals and patients with mild cognitive impairment and AD. However, that study paid little attention to the relationship between tactile angle discrimination and SCD. Therefore, a means of differentiating Normal Controls (NCs), elderly subjects with SCD, patients with amnestic Mild Cognitive Impairment (aMCI), and AD is urgently needed.

METHODS

In the present study, we developed a novel tactile discrimination device that uses angle stimulation applied to the index finger pad to identify very small differences in angle discrimination between the NC (n = 30), SCD (n = 30), aMCI (n = 30), and AD (n = 30) groups. Using a three-alternative forced-choice and staircase method, we analyzed the average accuracy and threshold of angle discrimination.

RESULTS

We found that accuracy significantly decreased while thresholds of angle discrimination increased in the groups in the following order: NC, SCD, aMCI, and AD. The area under the receiver operating characteristic curve also indicated that the tactile angle discrimination threshold was better than Mini-Mental State Examination scores in distinguishing NC individuals and SCD patients.

CONCLUSION

These findings emphasize the importance of tactile working memory dysfunction in explaining the cognitive decline in angle discrimination that occurs in SCD to AD patients and offer further insight into the very early detection of subjects with AD.

Correction: Axial variation of deoxyhemoglobin density as a source of the low-frequency time lag structure in blood oxygenation level-dependent signals

[This corrects the article DOI: 10.1371/journal.pone.0222787.].

Axial variation of deoxyhemoglobin density as a source of the low-frequency time lag structure in blood oxygenation level-dependent signals

Perfusion-related information is reportedly embedded in the low-frequency component of a blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI) signal. The blood-propagation pattern through the cerebral vascular tree is detected as an interregional lag variation of spontaneous low-frequency oscillations (sLFOs). Mapping of this lag, or phase, has been implicitly treated as a projection of the vascular tree structure onto real space. While accumulating evidence supports the biological significance of this signal component, the physiological basis of the “perfusion lag structure,” a requirement for an integrative resting-state fMRI-signal model, is lacking. In this study, we conducted analyses furthering the hypothesis that the sLFO is not only largely of systemic origin, but also essentially intrinsic to blood, and hence behaves as a virtual tracer. By summing the small fluctuations of instantaneous phase differences between adjacent vascular regions, a velocity response to respiratory challenges was detected. Regarding the relationship to neurovascular coupling, the removal of the whole lag structure, which can be considered as an optimized global-signal regression, resulted in a reduction of inter-individual variance while preserving the fMRI response. Examination of the T2* and S₀, or non-BOLD, components of the fMRI signal revealed that the lag structure is deoxyhemoglobin dependent, while paradoxically presenting a signal-magnitude reduction in the venous side of the cerebral vasculature. These findings provide insight into the origin of BOLD sLFOs, suggesting that they are highly intrinsic to the circulating blood.

[Overcoming Fear of Death in Home Caregiving]

This study aimed to clarify the factors for reducing the burden of caregivers caring for terminal patients. We conducted semi-structured interviews with bereaved caregivers, seeking those who had felt neither fear nor anxiety during caregiving; their responses were analyzed using the Steps for Coding and Theorization. The one caregiver who showed neither fear nor anxiety(1)believed in an afterlife,(2)sought a physician who would respect her belief,(3)sought respect for her medical decisions, and(4)found distance to the clinic to be a critical factor. Our findings suggest that doctors' respect for caregivers' beliefs may be an important factor in reducing caregiver burden at the end of life.

Simultaneous infrared thermal imaging and laser speckle imaging of brain temperature and cerebral blood flow in rats

Infrared thermal imaging of brain temperature changes is useful for evaluating cortical activity and disease states, such as stroke. However, the changes depend on a balance between changes in heat generation from metabolism and in heat convection related to blood flow. To discriminate between these effects and gain a clearer understanding of neurovascular metabolic coupling, brain temperature imaging must be improved to measure temperature and blood flow simultaneously. We develop an imaging technique that shows a two-dimensional (2-D) distribution of absolute brain temperature and relative cerebral blood flow changes in anesthetized rats by combining infrared thermal imaging with laser speckle imaging. The changes in brain metabolism and cerebral blood flow are achieved using two different anesthetics (isoflurane and α-chloralose) to evaluate our system. Isoflurane increased cerebral blood flow but decreased metabolism, whereas α-chloralose decreased both parameters. This technique enables simultaneous visualization of brain surface changes in temperature and cerebral blood flow in the same regions. This imaging system will permit further study of neurovascular metabolic coupling in normal and diseased brains.

Asymmetric Functional Connectivity of the Contra- and Ipsilateral Secondary Somatosensory Cortex during Tactile Object Recognition

In the somatosensory system, it is well known that the bilateral secondary somatosensory cortex (SII) receives projections from the unilateral primary somatosensory cortex (SI), and the SII, in turn, sends feedback projections to SI. Most neuroimaging studies have clearly shown bilateral SII activation using only unilateral stimulation for both anatomical and functional connectivity across SII subregions. However, no study has unveiled differences in the functional connectivity of the contra- and ipsilateral SII network that relates to frontoparietal areas during tactile object recognition. Therefore, we used event-related functional magnetic resonance imaging (fMRI) and a delayed match-to-sample (DMS) task to investigate the contributions of bilateral SII during tactile object recognition. In the fMRI experiment, 14 healthy subjects were presented with tactile angle stimuli on their right index finger and asked to encode three sample stimuli during the encoding phase and one test stimulus during the recognition phase. Then, the subjects indicated whether the angle of test stimulus was presented during the encoding phase. The results showed that contralateral (left) SII activity was greater than ipsilateral (right) SII activity during the encoding phase, but there was no difference during the recognition phase. A subsequent psycho-physiological interaction (PPI) analysis revealed distinct connectivity from the contra- and ipsilateral SII to other regions. The left SII functionally connected to the left SI and right primary and premotor cortex, while the right SII functionally connected to the left posterior parietal cortex (PPC). Our findings suggest that in situations involving unilateral tactile object recognition, contra- and ipsilateral SII will induce an asymmetrical functional connectivity to other brain areas, which may occur by the hand contralateral effect of SII.

Facilitation of Function and Manipulation Knowledge of Tools Using Transcranial Direct Current Stimulation (tDCS)

Using a variety of tools is a common and essential component of modern human life. Patients with brain damage or neurological disorders frequently have cognitive deficits in their recognition and manipulation of tools. In this study, we focused on improving tool-related cognition using transcranial direct current stimulation (tDCS). Converging evidence from neuropsychology, neuroimaging and non- invasive brain stimulation has identified the anterior temporal lobe (ATL) and inferior parietal lobule (IPL) as brain regions supporting action semantics. We observed enhanced performance in tool cognition with anodal tDCS over ATL and IPL in two cognitive tasks that require rapid access to semantic knowledge about the function or manipulation of common tools. ATL stimulation improved access to both function and manipulation knowledge of tools. The effect of IPL stimulation showed a trend toward better manipulation judgments. Our findings support previous studies of tool semantics and provide a novel approach for manipulation of underlying circuits.

Alteration of Venous Drainage Route in Idiopathic Normal Pressure Hydrocephalus and Normal Aging

Idiopathic normal pressure hydrocephalus (iNPH) is a highly prevalent condition in the elderly population; however, the underlying pathophysiology in relation to the aging process remains unclear. To investigate the effect of removal of cerebrospinal fluid by lumbar “tap test” on the cerebral circulation in patients with iNPH, 14 patients with “probable” iNPH were studied using a novel blood tracking technique based on blood oxygenation level-dependent (BOLD) magnetic resonance signal intensity. By tracking the propagation of the low-frequency component of the BOLD signal, extended venous drainage times were observed in the periventricular region of the patients, which was reversed by tap test. Interestingly, the venous drainage time in the periventricular region exhibited an age-related prolongation in the healthy control group. Additional regression analyses involving 81 control subjects revealed a dissociation of deep and superficial venous systems with increasing age, presumably reflecting focal inefficiency in the deep system. Our results not only provide insights into the etiology of iNPH, but also point to a potential non-invasive biomarker for screening iNPH.

Differential diagnosis of parkinsonian syndromes using dopamine transporter and perfusion SPECT

OBJECTIVE

We aimed to assess whether a combined analysis of dopamine transporter (DAT)- and perfusion-SPECT images (or either) could: (1) distinguish atypical parkinsonian syndromes (APS) from Lewy body diseases (LBD; majority Parkinson disease [PD]), and (2) differentiate among APS subgroups (progressive supranuclear palsy [PSP], corticobasal syndrome [CBS], and multiple system atrophy [MSA]).

METHODS

We recruited consecutive patients with neurodegenerative parkinsonian syndromes (LBD, n = 46; APS, n = 33). Individual [¹²³I]FP-CIT- and [¹²³I]iodoamphetamine-SPECT images were coregistered onto anatomical MRI segmented into brain regions. Striatal DAT activity and regional perfusion were extracted from each brain region for each patient and submitted to logistic regression analyses. Stepwise procedures were used to select predictors that should be included in the models to distinguish APS from LBD, and differentiate among the APS subgroups. Receiver-operating characteristic (ROC) analyses were performed to measure diagnostic power. Leave-one-out cross-validation (LOOCV) was performed to evaluate the diagnostic accuracy.

RESULTS

The model to discriminate APS from LBD showed that the area under the ROC curve (AUC) was 0.923, while the total diagnostic accuracy (TDA) was 86.1% in LOOCV. In the model to distinguish PSP, CBS, and MSA from LBD, the AUC/TDA values were 0.978/94.6%, 0.978/87.0%, and 0.880/80.3%, respectively. In the model to differentiate between CBS and MSA, MSA and PSP, and PSP and CBS, the AUC/TDA values were 0.967/91.3%, 0.920/88.0%, 0.875/77.8%, respectively.

CONCLUSION

An image-based automated classification using striatal DAT activity and regional perfusion patterns provided a good performance in the differential diagnosis of neurodegenerative parkinsonian syndromes without clinical information.

Prediction of Alzheimer's Disease in Amnestic Mild Cognitive Impairment Subtypes: Stratification Based on Imaging Biomarkers

BACKGROUND

Prediction of progression to Alzheimer's disease (AD) in amnestic mild cognitive impairment (MCI) is challenging because of its heterogeneity.

OBJECTIVE

To evaluate a stratification method on different cohorts and to investigate whether stratification in amnestic MCI could improve prediction accuracy.

METHODS

We identified 80 and 79 patients with amnestic MCI from different cohorts, respectively. They underwent baseline magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scans. We performed hierarchical clustering with three imaging biomarkers: Brain volume on MRI, left hippocampus grey matter loss on MRI, and left inferior temporal gyrus glucose hypometabolism on FDG-PET. Regions-of-interest for biomarkers were defined by the Automated Anatomical Labeling atlas. We performed voxel-wise statistical parametric mapping to explore differences between clusters in patterns of grey matter loss and glucose hypometabolism. We compared time to progression using an interval-censored parametric model. We evaluated predictive performance using logistic regression.

RESULTS

Similar clusters were found in different cohorts. MCI1 had the healthiest biomarker profile of cognitive performance and imaging biomarkers. MCI2 had cognitive performance and MRI measures intermediate between those of nonconverters and converters. MCI3 showed the severest reduction in brain volume and left hippocampal atrophy. MCI4 showed remarkable glucose hypometabolism in the left inferior temporal gyrus, and also demonstrated significant decreases in most cognitive scores, including non-memory functions. MCI4 showed the highest risk for progression. The prediction of progression of MCI2 especially benefited from the stratification.

CONCLUSION

Stratification with imaging biomarkers in amnestic MCI can be a good approach for improving predictive performance.

Reference Correlations for the Thermal Conductivity of Liquid Bismuth, Cobalt, Germanium and Silicon

The available experimental data for the thermal conductivity of liquid bismuth, cobalt, germanium and silicon have been critically examined with the intention of establishing thermal conductivity reference correlations. All experimental data have been categorized into primary and secondary data according to the quality of measurement specified by a series of criteria. The proposed standard reference correlations for the thermal conductivity of liquid bismuth, cobalt, germanium, and silicon are respectively characterized by uncertainties of 10, 15, 16 and 9.5% at the 95% confidence level.

Auditory Mismatch Negativity in Response to Changes of Counter-Balanced Interaural Time and Level Differences

Interaural time differences (ITD) and interaural level differences (ILD) both signal horizontal sound source location. To achieve a unified percept of our acoustic environment, these two cues require integration. In the present study, we tested this integration of ITD and ILD with electroencephalography (EEG) by measuring the mismatch negativity (MMN). The MMN can arise in response to spatial changes and is at least partly generated in auditory cortex. In our study, we aimed at testing for an MMN in response to stimuli with counter-balanced ITD/ILD cues. To this end, we employed a roving oddball paradigm with alternating sound sequences in two types of blocks: (a) lateralized stimuli with congruently combined ITD/ILD cues and (b) midline stimuli created by counter-balanced, incongruently combined ITD/ILD cues. We observed a significant MMN peaking at about 112–128 ms after change onset for the congruent ITD/ILD cues, for both lower (0.5 kHz) and higher carrier frequency (4 kHz). More importantly, we also observed significant MMN peaking at about 129 ms for incongruently combined ITD/ILD cues, but this effect was only detectable in the lower frequency range (0.5 kHz). There were no significant differences of the MMN responses for the two types of cue combinations (congruent/incongruent). These results suggest that—at least in the lower frequency ranges (0.5 kHz)—ITD and ILD are processed independently at the level of the MMN in auditory cortex.

High frequency activity overriding cortico-cortical evoked potentials reflects altered excitability in the human epileptic focus

OBJECTIVE

We aimed to clarify that high frequency activity (HFA) of cortico-cortical evoked potentials (CCEPs), elicited by single pulse electrical stimulation (SPES), reflects cortical excitability.

METHODS

We recruited 16 patients with refractory partial epilepsy who had chronic subdural electrode implantation for presurgical evaluation. A repetitive SPES was given to (1) the seizure onset zone (SOZ) and (2) the control cortices (non-seizure onset zone: nSOZ). CCEPs were recorded from the neighboring cortices within SOZ and nSOZ. We applied short-time Fourier transform to obtain the induced responses for the timing of early (<50ms after SPES) and late CCEP components and analyzed the logarithmic power change for ripple (<200Hz) and fast ripple (>200Hz) bands.

RESULTS

Twenty-one clear CCEPs were recorded for both the SOZ and nSOZ. The HFA power of early CCEPs in SOZ significantly increased compared to that in nSOZ in both frequency bands, particularly in mesial temporal lobe epilepsy (MTLE).

CONCLUSION

Similar to the features of spontaneous pathological HFOs, the power of stimulus-induced HFAs in SOZ were greater than that outside SOZ, particularly in MTLE.

SIGNIFICANCE

HFA overriding CCEPs can be a surrogate marker of cortical excitability in epileptic focus.

Remembering my friends: Medial prefrontal and hippocampal contributions to the self-reference effect on face memories in a social context

Memories associated with the self are remembered more accurately than those associated with others. The memory enhancement related to the self is known as the self-reference effect (SRE). However, little is known regarding the neural mechanisms underlying the SRE in a social context modulated by social relationships. In the present fMRI study, we investigated encoding-related activation of face memories encoded with the self-referential process in a social context that was manipulated by imagining a person-to-person relationship. Healthy young adults participated in the present study. During encoding, participants encoded unfamiliar target faces by imagining a future friendship with themselves (Self), their friends (Friend), or strangers (Other). During retrieval, participants were presented with target and distracter faces one by one, and they judged whether each face had been previously learned. In the behavioral results, target faces encoded in the Self condition were remembered more accurately than those encoded in the Other condition. fMRI results demonstrated that encoding-related activation in the medial prefrontal cortex (mPFC) was significantly greater in the Self condition than in the Friend or Other conditions. In addition, the generalized psycho-physiological interaction (gPPI) analysis showed that functional connectivity between activation in the hippocampus and the cortical midline structures (CMSs), including the mPFC and precuneus, was significant in the Self but not in the Other condition. These findings suggest that the SRE in a social context could be involved in the interaction between the CMS regions, which are related to the self-referential process, and the hippocampus related to the memory process. Hum Brain Mapp 38:4256-4269, 2017. © 2017 Wiley Periodicals, Inc.

A Resilient, Non-neuronal Source of the Spatiotemporal Lag Structure Detected by BOLD Signal-Based Blood Flow Tracking

Recent evidence has suggested that blood oxygenation level-dependent (BOLD) signals convey information about brain circulation via low frequency oscillation of systemic origin (sLFO) that travels through the vascular structure ("lag mapping"). Prompted by its promising application in both physiology and pathology, we examined this signal component using multiple approaches. A total of 30 healthy volunteers were recruited to perform two reproducibility experiments at 3 Tesla using multiband echo planar imaging. The first experiment investigated the effect of denoising and the second was designed to study the effect of subject behavior on lag mapping. The lag map's intersession test-retest reproducibility and image contrast were both diminished by removal of either the neuronal or the non-neuronal (e.g., cardiac, respiratory) components by independent component analysis-based denoising, suggesting that the neurovascular coupling also comprises a part of the BOLD lag structure. The lag maps were, at the same time, robust against local perfusion increases due to visuomotor task and global changes in perfusion induced by breath-holding at the same level as the intrasession reliability. The lag structure was preserved after time-locked averaging to the visuomotor task and breath-holding events, while any preceding signal changes were canceled out for the visuomotor task, consistent with the passive effect of neurovascular coupling in the venous side of the vasculature. These findings support the current assumption that lag mapping primarily reflects vascular structure despite the presence of sLFO perturbation of neuronal or non-neuronal origin and, thus, emphasize the vascular origin of the lag map, encouraging application of BOLD-based blood flow tracking.

Lateralization of intrinsic frontoparietal network connectivity and symptoms in schizophrenia

It has been frequently reported that schizophrenia patients have reduced functional lateralization in the areas related to language processing. Furthermore, there is evidence supporting that schizophrenia patients have disrupted functional connectivity in the bilateral frontoparietal networks (FPNs), of which the left is strongly associated with a cognition-language paradigm, using resting-state functional magnetic resonance imaging (rsfMRI). To examine the laterality of resting-state functional connectivity in schizophrenia, we investigated the bilateral FPNs. We investigated 41 schizophrenia and 35 healthy participants using independent component analysis for rsfMRI. We extracted mean connectivity values of both left and right FPNs and calculated their laterality index by (left - right)/(left + right). Subsequently, we investigated group differences of these values and the correlation between these values and symptoms. In schizophrenia, mean connectivity values of both left and right FPNs were significantly lower than in healthy controls, whereas their laterality indices were not significantly different. However, correlation analyses revealed that the laterality index was negatively correlated with positive symptoms, and that mean connectivity of left FPN was negatively correlated with depressive symptoms in schizophrenia. Our results suggest that language-related networks and their laterality might be one of the neural correlates of schizophrenia symptoms.

Clinical impact of intraoperative CCEP monitoring in evaluating the dorsal language white matter pathway

In order to preserve postoperative language function, we recently proposed a new intraoperative method to monitor the integrity of the dorsal language pathway (arcuate fasciculus; AF) using cortico-cortical evoked potentials (CCEPs). Based on further investigations (20 patients, 21 CCEP investigations), including patients who were not suitable for awake surgery (five CCEP investigations) or those without preoperative neuroimaging data (eight CCEP investigations including four with untraceable tractography due to brain edema), we attempted to clarify the clinical impact of this new intraoperative method. We monitored the integrity of AF by stimulating the anterior perisylvian language area (AL) by recording CCEPs from the posterior perisylvian language area (PL) consecutively during both general anesthesia and awake condition. After tumor resection, single-pulse electrical stimuli were also applied to the floor of the removal cavity to record subcortico-cortical evoked potentials (SCEPs) at AL and PL in 12 patients (12 SCEP investigations). We demonstrated that (1) intraoperative dorsal language network monitoring was feasible even when patients were not suitable for awake surgery or without preoperative neuroimaging studies, (2) CCEP is a dynamic marker of functional connectivity or integrity of AF, and CCEP N1 amplitude could even become larger after reduction of brain edema, (3) a 50% CCEP N1 amplitude decline might be a cut-off value to prevent permanent language dysfunction due to impairment of AF, (4) a correspondence (<2.0 ms difference) of N1 onset latencies between CCEP and the sum of SCEPs indicates close proximity of the subcortical stimulus site to AF (<3.0 mm). Hum Brain Mapp 38:1977-1991, 2017. © 2017 Wiley Periodicals, Inc.

Corpus Callosum Pathology as a Potential Surrogate Marker of Cognitive Impairment in Diffuse Axonal Injury

Diffuse axonal injury is a major form of traumatic brain injury. Neuropsychological assessments and high-resolution structural MRI were conducted using T1-weighted and diffusion tensor imaging. This study included 10 patients with diffuse axonal injury (all men, mean age 30.8±10.5 years) and 12 age- and sex-matched normal control participants. Patients with diffuse axonal injury had widespread volume reductions and lower fractional anisotropy in the corpus callosum (CC) compared with controls. Furthermore, cognitive processing speed was associated with reductions in white matter volume and fractional anisotropy in the CC. These findings suggest that CC pathology may be a potential surrogate marker of the cognitive deficits in these patients.

Detection of cerebral amyloid angiopathy by 3-T magnetic resonance imaging and amyloid positron emission tomography in a patient with subcortical ischaemic vascular dementia

The patient was an 81-year-old man who had been treated for hypertension for several decades. In 2012, he developed gait disturbance and mild amnesia. One year later, his gait disturbance worsened, and he developed urinary incontinence. Conventional brain magnetic resonance imaging using T ₂ -weighted images and fluid-attenuated inversion recovery showed multiple lacunar infarctions. These findings fulfilled the diagnostic criteria for subcortical ischaemic vascular dementia. However, susceptibility weighted imaging showed multiple lobar microbleeds in the bilateral occipitoparietal lobes, and double inversion recovery and 3-D fluid-attenuated inversion recovery images on 3-T magnetic resonance imaging revealed cortical microinfarctions in the left parietal-temporo-occipito region. Pittsburgh compound B-positron emission tomography revealed diffuse uptake in the cerebral cortex. Therefore, we diagnosed the patient with subcortical ischaemic vascular dementia associated with Alzheimer's disease. The use of the double inversion recovery and susceptibility weighted imaging on 3-T magnetic resonance imaging may be a supplemental strategy for diagnosing cerebral amyloid angiopathy, which is closely associated with Alzheimer's disease.

A multicenter, randomized, placebo-controlled trial for cilostazol in patients with mild cognitive impairment: The COMCID study protocol

Introduction

There are currently no effective treatments preventing conversion from mild cognitive impairment (MCI) to Alzheimer's disease. Cilostazol is a selective type-3 phosphodiesterase inhibitor that ameliorates accumulation of amyloid-β and has prevented cognitive decline in rodent models. Furthermore, cilostazol is known to suppress platelet aggregation, protect vascular endothelia, dilate vessels, and increase cerebral blood flow. Beneficial effects have also been shown in observational cohort studies, demonstrating the need for a prospective clinical trial.

Methods

The Cilostazol for prevention of COnversion from MCI to Dementia (COMCID) study is a double-blind, randomized phase II study of patients with MCI. Participants will receive cilostazol or placebo for 96 weeks. The primary objective is to evaluate whether cilostazol slows down cognitive decline measured by the Mini-Mental State Examination. Secondary objectives are assessing time to conversion from MCI to dementia and assessing incremental changes in several psychological assessment scales.

Discussion

The COMCID trial will identify the therapeutic potential of cilostazol. This trial, which is based on a drug repositioning strategy, may aid the development of a neurovascular treatment for neurocognitive disorders.

Neural mechanisms and personality correlates of the sunk cost effect

The sunk cost effect, an interesting and well-known maladaptive behavior, is pervasive in real life, and thus has been studied in various disciplines, including economics, psychology, organizational behavior, politics, and biology. However, the neural mechanisms underlying the sunk cost effect have not been clearly established, nor have their association with differences in individual susceptibility to the effect. Using functional magnetic resonance imaging, we investigated neural responses induced by sunk costs along with measures of core human personality. We found that individuals who tend to adhere to social rules and regulations (who are high in measured agreeableness and conscientiousness) are more susceptible to the sunk cost effect. Furthermore, this behavioral observation was strongly mediated by insula activity during sunk cost decision-making. Tight coupling between the insula and lateral prefrontal cortex was also observed during decision-making under sunk costs. Our findings reveal how individual differences can affect decision-making under sunk costs, thereby contributing to a better understanding of the psychological and neural mechanisms of the sunk cost effect.

Gradual cerebral hypoperfusion in spontaneously hypertensive rats induces slowly evolving white matter abnormalities and impairs working memory

Rats subjected to bilateral common carotid arteries (CCAs) occlusion or 2-vessel occlusion (2VO) have been used as animal models of subcortical ischemic vascular dementia (SIVD). However, these models possess an inherent limitation in that cerebral blood flow (CBF) drops sharply and substantially after ligation of CCAs without vascular risk factors and causative small vessel changes. We previously reported a novel rat model of 2-vessel gradual occlusion (2VGO) in which ameroid constrictors (ACs) were placed bilaterally in the CCAs of Wistar-Kyoto rats. To simulate SIVD pathology more closely, we applied ACs in spontaneously hypertensive rats (SHRs), which naturally develop small vessel pathology, and compared their phenotypes with SHR-2VO and sham-operated rats. The mortality rate of the SHR-2VGO was 0% while that of the SHR-2VO was 56.5%. The CBF of the SHR-2VO dropped to 50% of the baseline level at 3 h, whereas the SHR-2VGO showed a gradual CBF reduction reaching only 68% of the baseline level at seven days. The SHR-2VGO showed slowly evolving white matter abnormalities and subsequent spatial working memory impairments of a similar magnitude to the remaining SHR-2VO at 28 days. We suggest the SHR-2VGO robustly replicates selective aspects of the pathophysiology of SIVD with low mortality rate.

Dynamic interactions of the cortical networks during thought suppression

OBJECTIVES

Thought suppression has spurred extensive research in clinical and preclinical fields, particularly with regard to the paradoxical aspects of this behavior. However, the involvement of the brain's inhibitory system in the dynamics underlying the continuous effort to suppress thoughts has yet to be clarified. This study aims to provide a unified perspective for the volitional suppression of internal events incorporating the current understanding of the brain's inhibitory system.

MATERIALS AND METHODS

Twenty healthy volunteers underwent functional magnetic resonance imaging while they performed thought suppression blocks alternating with visual imagery blocks. The whole dataset was decomposed by group-independent component analysis into 30 components. After discarding noise components, the 20 valid components were subjected to further analysis of their temporal properties including task-relatedness and between-component residual correlation.

RESULTS

Combining a long task period and a data-driven approach, we observed a right-side-dominant, lateral frontoparietal network to be strongly suppression related. This network exhibited increased fluctuation during suppression, which is compatible with the well-known difficulty of suppression maintenance.

CONCLUSIONS

Between-network correlation provided further insight into the coordinated engagement of the executive control and dorsal attention networks, as well as the reciprocal activation of imagery-related components, thus revealing neural substrates associated with the rivalry between intrusive thoughts and the suppression process.

Altered striatal circuits underlie characteristic personality traits in Parkinson's disease

Patients with Parkinson's disease (PD) have been suggested to share personality traits characterised by low novelty-seeking and high harm-avoidance. Although a link between novelty-seeking and dopamine is hypothesised, the link is not fully supported by 6-[(18)F]fluoro-L-dopa positron emission tomography (PET) studies. Meanwhile, tractography studies with magnetic resonance imaging (MRI) link personality to the connectivity of the striatum in healthy subjects. Here, we investigated neurochemical and anatomical correlates of characteristic personality traits in PD. Sixteen PD patients and 28 healthy controls were assessed using the Temperament and Character Inventory. All patients and 17 randomly selected controls were scanned with 2β-carbomethoxy-3β-(4-fluorophenyl)-[N-(11)C-methyl]tropane ([(11)C]CFT) PET to measure striatal dopamine transporter availability. All subjects were scanned with MRI to evaluate the connectivity of the striatum using probabilistic tractography. PET findings revealed no correlation of novelty-seeking and harm-avoidance with [(11)C]CFT uptake in patients or controls. Novelty-seeking correlated positively with the connectivity strength of the striatum with the hippocampus and amygdala in both patients and controls. Harm-avoidance and the fibre connectivity strength of the striatum including ventral area with the amygdala correlated negatively in patients and positively in controls, which differed significantly between the groups. Our data support the notion that the fibre connectivity of the striatum with limbic and frontal areas underlies the personality profile. Furthermore, our findings suggest that higher harm-avoidance in PD is linked to alterations of the network, including the nucleus accumbens and amygdala.

In vivo Magnetic Resonance Microscopy and Hypothermic Anaesthesia of a Disease Model in Medaka

In medical and pharmacological research, various human disease models in small fish, such as medaka (Oryzias latipes), have been created. To investigate these disease models noninvasively, magnetic resonance imaging (MRI) is suitable because these small fish are no longer transparent as adults. However, their small body size requires a high spatial resolution, and a water pool should be avoided to maximize the strength of MRI. We developed in vivo magnetic resonance microscopy (MR microscopy) without a water pool by combining hypothermic anaesthesia and a 14.1 T MR microscope. Using in vivo MR microscopy, we noninvasively evaluated the hepatic steatosis level of a non-alcoholic fatty liver disease model in medaka and followed the individual disease progression. The steatosis level was quantified by the MRI-estimated proton density fat-fraction (MRI-PDFF), which estimates the triglyceride fat concentration in liver tissue and is recognized as an imaging biomarker. The MRI-PDFF results agreed with a histological analysis. Moreover, we optimized the hypothermic anaesthesia procedure to obtain a recovery proportion of 1 in the experiment involving MR microscopy. Recovered medaka could not be distinguished from naïve medaka after the experiment. Therefore, the in vivo MR microscopy will expand the possibilities of a human disease model in fish.

Epileptic network of hypothalamic hamartoma: An EEG-fMRI study

OBJECTIVE

To investigate the brain networks involved in epileptogenesis/encephalopathy associated with hypothalamic hamartoma (HH) by EEG with functional MRI (EEG-fMRI), and evaluate its efficacy in locating the HH interface in comparison with subtraction ictal SPECT coregistered to MRI (SISCOM).

METHODS

Eight HH patients underwent EEG-fMRI. All had gelastic seizures (GS) and 7 developed other seizure types. Using a general linear model, spike-related activation/deactivation was analyzed individually by applying a hemodynamic response function before, at, and after spike onset (time-shift model=-8-+4s). Group analysis was also performed. The sensitivity of EEG-fMRI in identifying the HH interface was compared with SISCOM in HH patients having unilateral hypothalamic attachment.

RESULTS

EEG-fMRI revealed activation and/or deactivation in subcortical structures and neocortices in all patients. 6/8 patients showed activation in or around the hypothalamus with the HH interface with time-shift model before spike onset. Group analysis showed common activation in the ipsilateral hypothalamus, brainstem tegmentum, and contralateral cerebellum. Deactivation occurred in the default mode network (DMN) and bilateral hippocampi. Among 5 patients with unilateral hypothalamic attachment, activation in or around the ipsilateral hypothalamus was seen in 3 using EEG-fMRI, whereas hyperperfusion was seen in 1 by SISCOM.

SIGNIFICANCE

Group analysis of this preliminary study may suggest that the commonly activated subcortical network is related to generation of GS and that frequent spikes lead to deactivation of the DMN and hippocampi, and eventually to a form of epileptic encephalopathy. Inter-individual variance in neocortex activation explains various seizure types among patients. EEG-fMRI enhances sensitivity in detecting the HH interface compared with SISCOM.

A Neural Mechanism of Preference Shifting Under Zero Price Condition

In everyday life, free products have a strong appeal to us, even if we do not need them. Behavioral studies demonstrated that people have a tendency to switch their preference from preferred more expensive products to less preferable, cheaper alternatives, when the cheaper option becomes free. However, the neural representation of this behavioral anomaly called “Zero price” is still unclear. Using fMRI, we studied subjects while they performed binary preference choice task for items with different prices. We found that zero-related change of preference was associated with activation of the choice network, which includes inferior parietal lobule (IPL), posterior cingulate cortex and medial prefrontal cortex. Moreover, the amount of activation in medial prefrontal cortex was positively correlated with the subjective happiness score of getting free products. Our findings suggest that the Zero-price effect is driven by affective evaluations during decision-making.

The 'when' and 'where' of semantic coding in the anterior temporal lobe: Temporal representational similarity analysis of electrocorticogram data

Electrocorticograms (ECoG) provide a unique opportunity to monitor neural activity directly at the cortical surface. Ten patients with subdural electrodes covering ventral and lateral anterior temporal regions (ATL) performed a picture naming task. Temporal representational similarity analysis (RSA) was used, for the first time, to compare spatio-temporal neural patterns from the ATL surface with pre-defined theoretical models. The results indicate that the neural activity in the ventral subregion of the ATL codes semantic representations from 250 msec after picture onset. The observed activation similarity was not related to the visual similarity of the pictures or the phonological similarity of their names. In keeping with convergent evidence for the importance of the ATL in semantic processing, these results provide the first direct evidence of semantic coding from the surface of the ventral ATL and its time-course.