Altered functional connectivity related to white matter changes inside the working memory network at the very early stage of MS

Multiple sclerosis: Cognition and saccadic eye movements

Ocular motor abnormalities are frequently reported in Multiple Sclerosis (MS), the most salient of which are well represented by the commonly used clinical measure, the EDSS. However, cognitive function, which is poorly represented by this scale, may also be ascertained from ocular motor measures, suggesting that an analysis of eye movements has the potential to extend and complement this more conventional measure. The generation of single and triple-step memory-guided saccades was investigated in 25 individuals with MS and a comparable number of neurologically healthy individuals matched for age and IQ. Experimental measures were correlated with a battery of neuropsychological tests evaluating attentional, working memory and executive processes, the cognitive domains most commonly compromised in MS. For single memory-guided saccades, MS patients were less accurate and generated more erroneous responses to non-target stimuli. Saccadic latencies were also prolonged. For triple-step memory-guided saccades, MS patients were less accurate and more variable. A number of significant correlations were revealed between measures of each of these characteristics and scores on the range of neuropsychological assessments. These ocular motor measures demonstrate considerable sensitivity with respect to evaluating cognitive function in MS, particularly working memory and inhibitory control processes. This suggests that they could represent the foundation of a user-friendly surrogate marker of disease severity and progression in MS.

Imaging structural and functional connectivity: towards a unified definition of human brain organization?

PURPOSE OF REVIEW

Diffusion tractography and functional/effective connectivity MRI provide a better understanding of the structural and functional human brain connectivity. This review will underline the major recent methodological developments and their exceptional respective contributions to physiological and pathophysiological studies in vivo. We will also emphasize the benefits provided by computational models of complex networks such as graph theory.

RECENT FINDINGS

Imaging structural and functional brain connectivity has revealed the complex brain organization into large-scale networks. Such an organization not only permits the complex information segregation and integration during high cognitive processes but also determines the clinical consequences of alterations encountered in development, ageing, or neurological diseases. Recently, it has also been demonstrated that human brain networks shared topological properties with the so-called 'small-world' mathematical model, allowing a maximal efficiency with a minimal energy and wiring cost.

SUMMARY

Separately, magnetic resonance tractography and functional MRI connectivity have both brought new insights into brain organization and the impact of injuries. The small-world topology of structural and functional human brain networks offers a common framework to merge structural and functional imaging as well as dynamical data from electrophysiology that might allow a comprehensive definition of the brain organization and plasticity.

Efficiency of cognitive control recruitment in the very early stage of multiple sclerosis: a one-year fMRI follow-up study

Functional magnetic resonance imaging (FMRI) studies have established that patients with multiple sclerosis show stronger activation in the lateral prefrontal cortices (LPFC) than healthy control subjects during effortful cognitive tasks. The aim of the present study was to assess the impact of these activation changes on cognitive performances. In addition to 19 controls, who were tested at a single time-point to define a standard pattern of fMRI activation during the performance of the Paced Auditory Serial Addition Task (PASAT), 13 patients with clinically isolated syndrome underwent a longitudinal fMRI examination while performing the PASAT at the beginning of the study (M0) and one year later (M12). Relative to the M0 scores, PASAT performances improved in eight patients (group A) and either decreased ( n = 4) or remained unchanged ( n = 1) (group B) in five patients at M12. Random effect analyses (SPM2; Wellcome Institute, London, England) were performed to compare intra-group time-related effects on brain activation (paired t-test between M0 and M12), and inter-group differences were also compared between the two groups of patients (analysis of covariance with PASAT performances as the covariate). Relative to group B, group A showed larger increase in activation between M0 and M12 in the right LPFC. In the whole group of patients, interaction analyses showed that the differences in the PASAT scores between M0 and M12 were correlated with the differences in activation observed in the right LPFC. This longitudinal study shows that in patients with early multiple sclerosis, the increased levels of activation in the right LPFC was associated with improved individual working memory and processing speed performances.

Spatio-temporal characteristics of low-frequency BOLD signal fluctuations in isoflurane-anesthetized rat brain

We studied the spatio-temporal characteristics of the resting state low-frequency fluctuations in fMRI-BOLD signal in isoflurane-anesthetized rats. fMRI-BOLD measurements at 9.4 T were made during normal and exsanguinated condition previously known to alter cerebral blood flow (CBF) fluctuations in anesthetized rats. fMRI signal time series were low pass filtered and studied by spectral analysis. During normal conditions, baseline mean arterial pressure (MAP) was 110+/-10 mm Hg and low-frequency fluctuations in BOLD signal were observed in the frequency range of 0.01 to 0.125 Hz. Following blood withdrawal (exsanguination), MAP decreased to 68+/-7 mm Hg, resulting in an increase in the amplitude of the low-frequency fluctuations in BOLD signal time series and an increase in power at several frequencies between 0.01 and 0.125 Hz. Spatially, the BOLD fluctuations were confined to the cortex and thalamus spanning both hemispheres with sparse presence in the caudate putamen and hippocampus during both normal and exsanguinated states. Spatial distribution of the low-frequency fluctuations in BOLD signal, from cross-correlation analysis, indicates substantial inter-hemispheric synchrony similar to that observed in the conscious human brain. The behavior of the resting state BOLD signal fluctuations similar to CBF fluctuations during exsanguination indicates a myogenic dependence. Also, a high inter-hemispheric synchrony combined with different phase characteristics of the low-frequency BOLD fluctuations particularly in the hippocampus relative to the cortex emphasizes distinct functional networks.

Brain activation patterns elicited by the `Faces Symbol Test' — a pilot fMRI study

The Faces Symbol Test (FST) has recently been proposed as a brief and patient-friendly screening instrument for the assessment of cognitive dysfunction in patients with multiple sclerosis (MS). However, in contrast to well-established MS screening tests such as the Paced Auditory Serial Addition Test, the neural correlates of the FST have not been investigated so far. In the present study, we developed a functional MRI (fMRI) version of the FST to provide first data on brain regions and networks involved in this test. A sample of 19 healthy participants completed a version of the FST adapted for fMRI, requiring matching of faces and symbols in a multiple choice test and two further experimental conditions drawing on cognitive subcomponents (face matching and symbol matching). Imaging data showed a differential involvement of a fronto-parieto-occipital network in the three conditions. The most demanding FST condition elicited brain activation patterns related with sustained attention and executive control. These results suggest that the FST recruits brain networks critical for higher-order cognitive functions often impaired in MS patients. Multiple Sclerosis 2008; 14: 354—363. http://msj.sagepub.com

Application of fMRI to the study of multiple sclerosis: an update

During the past decade, functional MRI studies in patients with multiple sclerosis (MS) have consistently shown that the variable effectiveness of recovery mechanisms following disease-related tissue injury is one of the factors that might explain, at least partially, the paucity of the correlation between clinical and MRI findings in these patients. More recently, technical developments resulted in an improvement of acquisition and post-processing schemes that, in turn, allowed us to further characterize the functional and structural abnormalities of specific regions of the CNS, thus ameliorating the understanding of the mechanisms associated with the clinical manifestations and disability accumulation in MS. This review focuses on such recent achievements and provides an update of functional MRI studies of MS performed in the past few years.

Impairment of movement-associated brain deactivation in multiple sclerosis: further evidence for a functional pathology of interhemispheric neuronal inhibition

Motor control demands coordinated excitation and inhibition across distributed brain neuronal networks. Recent work has suggested that multiple sclerosis (MS) may be associated with impairments of neuronal inhibition as part of more general progressive impairments of connectivity. Here, we report results from a prospective, multi-centre fMRI study designed to characterise the changes in patients relative to healthy controls during a simple cued hand movement task. This study was conducted at eight European sites using 1.5 Tesla scanners. Brain deactivation during right hand movement was assessed in 56 right-handed patients with relapsing-remitting or secondary progressive MS without clinically evident hand impairment and in 60 age-matched, healthy subjects. The MS patients showed reduced task-associated deactivation relative to healthy controls in the pre- and postcentral gyri of the ipsilateral hemisphere in the region functionally specialised for hand movement control. We hypothesise that this impairment of deactivation is related to deficits of transcallosal connectivity and GABAergic neurotransmission occurring with the progression of pathology in the MS patients. This study has substantially extended previous observations with a well-powered, multicentre study. The clinical significance of these deactivation changes is still uncertain, but the functional anatomy of the affected region suggests that they could contribute to impairments of motor control.

Combining structural and functional neuroimaging data for studying brain connectivity: a review

Different brain areas are thought to be integrated into large-scale networks to support cognitive function. Recent approaches for investigating structural organization and functional coordination within these networks involve measures of connectivity among brain areas. We review studies combining in vivo structural and functional brain connectivity data, where (a) structural connectivity analysis, mostly based on diffusion tensor imaging is paired with voxel-wise analysis of functional neuroimaging data or (b) the measurement of functional connectivity based on covariance analysis is guided/aided by structural connectivity data. These studies provide insights into the relationships between brain structure and function. Promising trends involve (a) studies where both functional and anatomical connectivity data are collected using high-resolution neuroimaging methods and (b) the development of advanced quantitative models of integration.

Dehydration does not influence cardiovascular reactivity to behavioural stress in young healthy humans

Enhanced hydration increases the human cardiovascular reactivity to mental stress. If reduced water intake has the opposite effect, this would suggest controlling for water deprivation when studying such responses. Blood pressure, heart rate and parasympathetically dominated beat-to-beat heart rate fluctuations were assessed during resting baseline and mental stress. Two challenging cognitive-motor tasks, a 5-Choice Reaction Time Task (CRTT) and a Paced Auditory Serial Addition Task (PASAT), served as mental stress tests. Eight female and eight male volunteers were examined twice, after 24 h of water deprivation and after normal water intake (counterbalanced order, 7-day interval). Water deprivation resulted in moderate dehydration with a mean 2.6% decrease of total body weight. Dehydration did neither affect baseline blood pressure, heart rate, nor blood pressure reactivity to mental stress. However, dehydration slightly (-1.2 bpm) diminished heart rate reactivity to the PASAT (P = 0.03) and increased beat-to-beat heart rate fluctuations in response to the CRTT (P = 0.05). Dehydration intensified CRTT- and PASAT-induced reductions of beat-to-beat heart rate fluctuations in females (gender x dehydration interactions: P = 0.04-0.05). Moderate dehydration induced by water restriction has no effect on blood pressure reactivity to mental stress. The effects on heart rate reactivity are small. However, stress-induced parasympathetic withdrawal may be fortified during dehydration in females, which suggests controlling for water intake when studying such responses.

Inflammatory demyelination and neurodegeneration in early multiple sclerosis

A number of recent magnetic resonance imaging studies have challenged the classical view of multiple sclerosis (MS) as a "two-stage" disease where an early inflammatory demyelinating phase with focal macroscopic lesions formed in the white matter (WM) of the central nervous system is followed by a late neurodegenerative phase, which is believed to be a mere consequence of repeated inflammatory insults and irreversible demyelination. These studies have consistently shown the presence of diffuse normal-appearing WM damage, marked gray matter involvement and significant cortical functional reorganization, as well as the occurrence of the neurodegenerative component of MS from the earliest clinical stages of the disease with only a partial relation to MRI markers of inflammatory demyelination. The present review argues that MS can no longer be viewed as a "two-stage" disease, which suggests that the two pathological components are dissociated in time, but rather as a "simultaneous two-component" disease, where the relative contributions of the various pathological processes of the disease to the development of "fixed" disability, their relationship and their evolution over time need to be clarified. This new view of MS should inform the development of future research protocols to define its actual physiopathology and prompt the institution of early treatment which should ideally target not only inflammatory demyelination, but also the neurodegenerative aspects of the disease, as well as promote neuroprotection and enhance reparative mechanisms and adaptive functional reorganization of the cortex.

[Future of non conventional MR techniques in MS]

Although conventional magnetic resonance imaging (MRI) is used for diagnosing multiple sclerosis (MS) and monitoring disease activity and course, the correlation between conventional MRI data and clinical findings remains weak. This "clinical-MRI paradox" could be partly due to the lack of MRI specificity related to the heterogeneous pathological substrates of MS and to its inability to quantify the extent of damage in the normal-appearing tissue. Recently, non-conventional MRI techniques, including magnetization transfer MRI, diffusion tensor MRI, and proton MR spectroscopy have been applied to improve our understanding of the pathophysiology of MS. These techniques may provide information about structural and biochemical changes occurring within and outside macroscopic MS lesions (inflammation, demyelination, axonal loss), in particular in the normal-appearing white and grey matter. These techniques could also significantly improve our ability to monitor inflammatory demyelination and axonal injury. In the same way, functional MRI gives us the potential substrate to assess the mechanisms of adaptive cortical reorganization, which may limit the irreversible consequences of MS tissue injury.

Structure of WM bundles constituting the working memory system in early multiple sclerosis: a quantitative DTI tractography study

Working memory impairment is frequently observed in patients with early multiple sclerosis (MS). MRI and functional MRI studies have shown that working memory impairment is mostly due to diffuse white matter (WM) damage affecting the connectivity between distant cortical areas. However, working memory deficits in early MS patients can be either completely or partly masked by compensatory functional plasticity. It seems likely that concomitantly with the WM bundle injury resulting from pathological processes, the functional plasticity present in early MS patients may be accompanied by reactive structural WM plasticity. This structural plasticity may effectively compensate for connectivity disturbances and/or contribute to functional brain reorganization. The diffusion characteristics of WM bundles involved in working memory were assessed here by performing quantitative diffusion tensor imaging (DTI) tractography on 24 patients with early relapsing-remitting MS and 15 healthy control subjects. The DTI tractography findings showed that WM connections constituting the executive system of working memory were structurally impaired (the fractional anisotropy was lower than normal and the mean diffusivity, higher than normal). A significantly larger number of connections between the left and right thalami was concurrently observed in the MS patients than in the control subjects, which suggests that the WM is endowed with reactive structural plasticity.

Cardiovascular reactivity to mental stress is not affected by alpha2-adrenoreceptor activation or inhibition

RATIONALE

It has been postulated that cardiovascular reactivity to mental stress varies with tonic central sympathetic nervous system activity, but pharmacological evidence is missing.

OBJECTIVE

To test whether modulation of central sympathetic nervous system activity by alpha2-adrenergic agonism and antagonism affects cardiovascular reactivity to mental stress.

MATERIALS AND METHODS

On three five-stepped dose/concentration-response study days, 12 healthy male volunteers received intravenous infusions of dexmedetomidine (alpha2-agonist, target plasma concentrations: 0.04-0.32 ng/ml), yohimbine (alpha2-antagonist, doses: 0.016-0.125 mg/kg), and placebo, respectively. During each dose step, subjects performed a 5-Choice Reaction Time Task (CRTT) and a Paced Auditory Serial Addition Task (PASAT) to induce moderate mental stress. Prestress baseline, as well as stress-induced responses of heart rate, and noninvasive finger arterial blood pressure (Finapres) were assessed.

RESULTS

Prestress baseline heart rate and blood pressure decreased with increasing doses of dexmedetomidine and increased with increasing doses of yohimbine. However, dexmedetomidine and yohimbine did not affect stress-induced heart-rate and blood-pressure changes.

CONCLUSIONS

Cardiovascular reactivity to mental stress is not related to pharmacologically manipulated tonic central sympathetic nervous system activity by alpha2-adrenergic agonists and antagonists. These results do not support the assumption that cardiovascular reactivity is an index of tonic central sympathetic nervous system activity.

Intact subliminal processing and delayed conscious access in multiple sclerosis

Periventricular white matter damage affecting large bundles connecting distant cortical areas may constitute the main neuronal mechanism for the deficit of controlled information processing observed in patients with early multiple sclerosis (MS). Visual backward masking has been demonstrated to affect late stages of conscious perception involving long-range interactions between visual perceptual areas and higher level integrative cortices while leaving intact early feed-forward visual processing and even complex processing such as object recognition or semantic processing. We therefore hypothesized that patients with early MS would have an elevated masking threshold, because of an impairment of conscious perception whereas subliminal processing of masked stimuli would be preserved. Twenty-two patients with early MS and 22 normal controls performed two backward-masking experiments. We used Arabic digits as stimuli and varied quasi-continuously the temporal interval with a subsequent mask, thus allowing us to progressively "unmask" the stimuli. We finely quantified the visibility of the masked stimuli using both objective and subjective measures, thus obtaining accurate estimates of the threshold duration for access to consciousness. We also studied the priming effect caused by the variably masked numbers on a comparison task performed on a subsequently presented and highly visible target number. The threshold for access to consciousness of masked stimuli was elevated in MS patients compared to controls, whereas non-conscious processing of these stimuli, as measured by priming, was preserved. These findings suggest that conscious access to masked stimuli depends on the integrity of large-scale cortical integrative processes, which involve long-distance white matter projections, and are impaired due to diffuse demyelinating injury in patients with early MS.

Loss of interhemispheric inhibition in patients with multiple sclerosis is related to corpus callosum atrophy

Axonal injury and loss in the corpus callosum (CC) is characteristic of the pathology of multiple sclerosis (MS). Functional magnetic resonance imaging (fMRI) potentially allows neurophysiological consequences of this interhemispheric axonal loss to be defined quantitatively. Here we have used 3T fMRI to study the activation in the contralateral primary sensorimotor cortex and deactivation (mediated by transcallosal tracts) in the homologous ipsilateral region in 14 patients with MS and in 14 matched healthy controls during a simple hand-tapping task. Both healthy controls and MS patients showed similar activation in the motor cortex contralateral to the hand moved, but the patients showed a significantly smaller relative deactivation in the ipsilateral motor cortex (P = 0.002). The difference was accounted for by the sub-group of MS patients who previously had impairment of motor function of the hand tested (MS-phd). The CC of the whole patient group was significantly thinner than for the controls (P = 0.001). Atrophy of the CC was correlated with loss of deactivation for the whole patient group (r = -0.50, P = 0.035), but particularly for MS-phd (r = -0.914, P = 0.004). Interhemispheric physiological inhibition thus is impaired in patients with MS, potentially contributing to impairment of motor control. This work suggests one way in which FMRI monitoring of the transcallosal interactions in motor cortex could become a tool for evaluation of therapies that may enhance function in reversibly impaired pathways.

Structural and functional surrogates of cognitive impairment at the very early stage of multiple sclerosis

Following our previous reports based on parametric MRI methods (T(2)-weighted MRI, statistical mapping analysis of magnetization transfer ratio images and functional MRI) applied to a population of 18 patients with clinically isolated syndrome suggestive of multiple sclerosis, we have reviewed the possible structural and functional surrogates of MS that could explain the subtle cognitive impairment related to attention and working memory deficits evaluated with paced auditory serial addition test (PASAT). We propose that the brain substrates underlying cognitive impairment observed at the very early stage of MS are multifactorial. Several components could influence PASAT performances in patients: i) the extent of diffuse white matter damage, ii) the location of visible and non visible lesions, iii) the connectivity efficiency between distant brain functional areas involved in working memory processes and iv) the cortical reorganization. Nevertheless, individually, each of these parameters may have few influences on PASAT performance in patients. Using a multiregression model built with independent MR parameters, a very good evaluation of PASAT scores has been obtained in this limited number of patients explaining 90% of the variance. In conclusion, the different aspects of tissue and functional pathological brain underpinnings must be accounted to monitor accurately new therapeutic strategies for the treatment of early cognitive deficits related to MS.

Functional magnetic resonance imaging and cognition at the very early stage of MS

Dysfunction of high controlled information processing is present in patients with multiple sclerosis (MS) right at the beginning of the disease. One hypothesis is that disruption of communication inside large-scale cortical networks, occurring as a consequence of white matter damage, may constitute the anatomical substrate of cognitive impairment at the very early stage of MS. Disturbance of interregional synchronization might be the main pathogenic factor in controlled information processing deficiency in early MS. Preliminary functional MRI studies (fMRI) have provided important clues to corroborate the connectivity hypotheses. First, brain connectivity assessed by fMRI has brought new data about the influence of diffuse white matter damage on connectivity efficiency inside large-scale networks. These studies have suggested that connectivity disturbances occur inside the working memory network in patients at the very early stage of MS and appear related to the extent of structural white matter damage. Also, fMRI studies have suggested that patients may partially compensate for connectivity impairment by a greater cognitive control. Such a compensatory mechanism could limit the determinant functional impact of diffuse white matter damage on high controlled information processing.

Cortical reorganization during PASAT task in MS patients with preserved working memory functions

Cortical reorganization in multiple sclerosis (MS) is defined as a compensatory mechanism which requires MS patients to overactivate specific brain areas in order to perform the task as controls. To investigate this process with the Paced Auditory Serial Addition Test (PASAT) task, we selected 15 MS patients who performed the PASAT task within-normal limits and 10 healthy controls. Once selected, we used functional magnetic resonance imaging (fMRI) to investigate brain areas involved in PASAT performance in both groups. Results showed that the task activated the left frontal (BA6 and 9) and parietal cortex (BA7 and 40) in both groups, but MS patients showed a stronger activation in the left prefrontal cortex (BA9, 44 and 45) when compared with controls. These results confirmed those obtained post hoc by Audoin et al. [Audoin, B., Ibarrola, D., Ranjeva, J.P., Confort-Gouny, S., Malikova, I., Ali-Chérif, A.M., Pelletier, J., Cozzone, P., et al., 2003. Compensatory cortical activation observed by fMRI during cognitive task at the earliest stage of MS. Hum. Brain Mapp. 20, 51-58], and we interpreted this as showing true cortical reorganization.

Functional magnetic resonance imaging and multiple sclerosis

There is increasing evidence that the severity of the clinical manifestations of multiple sclerosis (MS) does not result simply from the extent of tissue destruction, rather it represents a complex balance between tissue damage, tissue repair and cortical reorganization. Functional magnetic resonance imaging provides information regarding the extent and nature of brain plasticity following MS-related structural injury, with the potential to limit the clinical manifestations of the disease. An altered recruitment of regions devoted normally to the performance of a given task and/or the recruitment of additional areas that are not typically activated by healthy people for performing that given task have been described in patients with MS, independent of their clinical phenotype, when investigating visual, cognitive and motor systems. These functional changes have been related not only to the extent and severity of brain damage within and outside T2-visible lesions and to the involvement of specific brain structures, but also to the degree of spinal cord and optic nerve involvement. It has also been suggested that an altered recruitment of specific brain regions might be associated with the appearance of clinical symptoms in MS, such as fatigue. Brain functional changes have been shown to be dynamic over time, not only after an acute relapse, but also in clinically stable patients. More recently, in patients at the earliest clinical stage of the disease, it has been shown that such changes might contribute to predicting the evolution to definite MS, and it has been postulated that dynamic changes of brain cortical activations might occur with the progression of the disease. An increased recruitment of the cerebral networks might represent the first step of cortical reorganization with the potential to maintain a normal level of function in the course of MS. The progressive failure of these mechanisms might, on the one hand, result in the activation of previously silent second-order compensatory areas, and on the other, contribute to the accumulation of irreversible disability.

Functional Magnetic Resonance Imaging and Multiple Sclerosis: The Evidence for Neuronal Plasticity

Blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI) has emerged as a powerful technique to visualize the localization of cerebral activity in both healthy and diseased brains. BOLD fMRI has been used to assess brain function in a variety of diseases, including multiple sclerosis (MS), and has shown that altered patterns of connectivity are used to recruit more widespread eloquent brain networks engaged in tasks relating to motor activity, sensory and cognitive function, and memory when compared to normal controls. This review will examine the evidence that functional reorganization is a consequence of demyelination and tissue loss in MS that may serve as an adaptive response to limit clinical disability. It remains unclear whether cerebral plasticity is a marker of permanent functional restructuring or a short-term compensatory response to injury. Long-term longitudinal studies that correlate fMRI activity with other MRI markers of disease burden and activity, as well as with clinical measures of disease activity and progression, are badly needed to determine fMRI's relevance to clinical practice and its place as a surrogate outcome measure in MS.