Noninvasive measurements of human brain temperature using volume-localized proton magnetic resonance spectroscopy

Early brain temperature elevation and anaerobic metabolism in human acute ischaemic stroke

Early after acute ischaemic stroke, elevation of brain temperature might augment tissue metabolic rate and conversion of ischaemic but viable tissue to infarction. This might explain the observed link between pyrexia, severe stroke and poor outcome. We tested this hypothesis by measuring brain temperature and lactate concentration with multi-voxel magnetic resonance spectroscopic imaging across the acute ischaemic stroke lesion and normal brain as determined on diffusion imaging. We compared patterns of lactate concentration (reported in 'institutional units') and temperature elevation in diffusion lesion core, potential penumbra, ipsilateral and contralateral normal brain and with stroke severity. Amongst 40 patients with moderate to severe acute stroke imaged up to 26 h after onset, lactate concentration was highest in the ischaemic lesion core (42 versus 26 units in potential penumbra, P < 0.05), whereas temperature was highest in the potential penumbra (37.7 versus 37.3 degrees C in lesion core, P < 0.05). Neither sub-regional temperature nor lactate concentration correlated with stroke severity. With increasing time after stroke, ipsilateral brain temperature did not change, but contralateral hemisphere temperature was higher in patients scanned at later times; lactate remained elevated in the lesion core, but declined in potential penumbral and ipsilateral normal tissue at later times. We conclude that early brain temperature elevation after stroke is not directly related to lactate concentration, therefore augmented metabolism is unlikely to explain the relationship between early pyrexia, severe stroke and poor outcome. Early brain temperature elevation may result from different mechanisms to those which raise body temperature after stroke. Further studies are required to determine why early brain temperature elevation is highest in potential penumbral tissue.

Noninvasive monitoring of brain temperature during mild hypothermia

The main purpose of this study was to verify the feasibility of brain temperature mapping with high-spatial- and reduced-spectral-resolution magnetic resonance spectroscopic imaging (MRSI). A secondary goal was to determine the temperature coefficient of water chemical shift in the brain with and without internal spectral reference. The accuracy of the proposed MRSI method was verified using a water and vegetable oil phantom. Selective decrease of the brain temperature of pigs was induced by intranasal cooling. Temperature reductions between 2 degrees C and 4 degrees C were achieved within 20 min. The relative changes in temperature during the cooling process were monitored using MRSI. The reference temperature was measured with MR-compatible fiber-optic probes. Single-voxel (1)H MRS was used for measurement of absolute brain temperature at baseline and at the end of cooling. The temperature coefficient of the water chemical shift of brain tissue measured by MRSI without internal reference was -0.0192+/-0.0019 ppm/degrees C. The temperature coefficients of the water chemical shift relative to N-acetylaspartate, choline-containing compounds and creatine were -0.0096+/-0.0009, -0.0083+/-0.0007 and -0.0091+/-0.0011 ppm/degrees C, respectively. The results of this study indicate that MRSI with high spatial and reduced spectral resolutions is a reliable tool for monitoring long-term temperature changes in the brain.

Amyloid-beta dynamics correlate with neurological status in the injured human brain

The amyloid-beta peptide (Abeta) plays a central pathophysiological role in Alzheimer's disease, but little is known about the concentration and dynamics of this secreted peptide in the extracellular space of the human brain. We used intracerebral microdialysis to obtain serial brain interstitial fluid (ISF) samples in 18 patients who were undergoing invasive intracranial monitoring after acute brain injury. We found a strong positive correlation between changes in brain ISF Abeta concentrations and neurological status, with Abeta concentrations increasing as neurological status improved and falling when neurological status declined. Brain ISF Abeta concentrations were also lower when other cerebral physiological and metabolic abnormalities reflected depressed neuronal function. Such dynamics fit well with the hypothesis that neuronal activity regulates extracellular Abeta concentration.

Bench to bedside strategies for optimizing neuroprotection following perinatal hypoxia-ischaemia in high and low resource settings

BACKGROUND

Therapeutic hypothermia gathers impetus in the developed world as a safe and effective therapy for term asphyxial encephalopathy. Although many questions still remain about the optimal application of hypothermic neuroprotection it is difficult to ignore the developing world where the prevalence of asphyxial encephalopathy is much higher. Experimental studies to optimize high tech cooling need to run in parallel with trials to determine the possible benefits of therapeutic hypothermia in low resource settings.

METHODS

We used a validated newborn piglet model of transient HI to determine (i) whether optimal neuroprotection occurs at different temperatures in the cortical and deep grey matter; (ii) the effect of body size on regional brain temperature under normothermia and hypothermia; (iii) the effect of insult severity on the therapeutic window duration; (iv) whether cooling using a water bottle is feasible. In this model hypoxia-ischaemia is induced by reversible occlusion of the common carotid arteries by remotely controlled vascular occluders and simultaneous reduction in the inspired oxygen fraction to 0.12. Intensive care can be administered to the piglet maintaining metabolic and physiological homeostasis throughout the experiment, and cerebral energy metabolism is monitored continuously providing quantitative measures of the HI insult, latent phase and secondary energy failure using phosphorus-31 ((31)P) magnetic resonance spectroscopy (MRS).

RESULTS

(i) The optimal temperature for cooling was lower in the cortex than deep grey matter. (ii) Cerebral temperatures were body-weight dependent: a smaller body weight led to a lower brain temperature especially with selective head cooling. (iii) Latent-phase duration is inversely related to insult severity. (iv) Low tech, simple cooling methods using a water bottle can induce and maintain moderate hypothermia.

CONCLUSIONS

Small shifts in brain temperature critically influence the survival of neuronal cells and body size critically influences brain-temperature gradients - smaller subjects have a larger surface area to brain volume and hence more heat is lost. The clinical implication is that smaller infants may require higher cap or body temperatures to avoid detrimental effects of over-zealous cooling. Latent-phase brevity may explain less effective neuroprotection following severe HI in some clinical studies. "Tailored" treatments which take into account individual and regional characteristics may increase the effectiveness of therapeutic hypothermia in the developed world. Low tech cooling methods using water bottles may be feasible although adequate staffing and monitoring would be required.

In vivo differentiation of N-acetyl aspartyl glutamate from N-acetyl aspartate at 3 Tesla

A method is described that allows the in vivo differentiation of N-acetyl aspartate (NAA) from N-acetyl aspartyl glutamate (NAAG) by in vivo MR spectroscopy (MRS) at 3 Tesla (3T). The method, which is based on MEGA-point-resolved spectroscopy (PRESS) editing, selectively targets the aspartyl spin system of one species while deliberately removing the other species from the spectrum. This allows quantitative measurements of NAA and NAAG without the need for fitting of unresolved peaks. White matter concentrations of NAA (6.7 +/- 0.3 mM) and NAAG (2.2 +/- 0.3 mM) were measured in 10 healthy volunteers to demonstrate the method.

Magnetic resonance-guided high-intensity ultrasound ablation of the prostate

OBJECTIVES

This paper describes our work in developing techniques and devices for magnetic resonance (MR)-guided high-intensity ultrasound ablation of the prostate and includes review of relevant literature.

METHODS

Catheter-based high-intensity ultrasound applicators, in interstitial and transurethral configurations, were developed to be used under MR guidance. Magnetic resonance thermometry and the relevant characteristics and artifacts were evaluated during in vivo thermal ablation of the prostate in 10 animals. Contrast-enhanced MR imaging (MRI) and diffusion-weighted MRI were used to assess tissue damage and compared with histology.

RESULTS

During evaluation of these applicators, MR thermometry was used to monitor the temperature distributions in the prostate in real time. Magnetic resonance-derived maximum temperature thresholds of 52 degrees C and thermal dose thresholds of 240 minutes were used to control the extent of treatment and qualitatively correlated well with posttreatment imaging studies and histology. The directional transurethral devices are selective in their ability to target well-defined regions of the prostate gland and can be rotated in discrete steps to conform treatment to prescribed boundaries. The curvilinear applicator is the most precise of these directional techniques. Multisectored transurethral applicators, with dynamic angular control of heating and no rotation requirements, offer a fast and less complex means of treatment with less selective contouring.

CONCLUSIONS

The catheter-based ultrasound devices can produce spatially selective regions of thermal destruction in prostate. The MR thermal imaging and thermal dose maps, obtained in multiple slices through the target volume, are useful for controlling therapy delivery (rotation, power levels, duration). Contrast-enhanced T1-weighted MRI and diffusion-weighted imaging are useful tools for assessing treatment.

Multimodal ultrasound mediated drug release model in local cancer therapy

Increased cancer survival rates over the last decades are probably less due to advances of a single treatment modality than to optimization of adjuvant treatment procedures. The efficiency of drug delivery in solid tumours is crucial for achieving local tumour control as cytotoxic agents do not target cancer cells selectively. To enhance tumour uptake and selectivity of drugs, liposomally encapsulated microbubbles with drugs or temperature sensitive liposomes with therapeutics have been suggested as new drug delivery vehicles, in combination with ultrasound or hyperthermia, respectively. The presented release model goes beyond simple drug delivery or traditional adjuvant therapies. It represents targeting, real time monitoring and imaging, and exerts concurrent application of therapeutic modalities, within a multimodal treatment regime, thus enhancing synergism. An appropriate diagnostic tool is applied to determine the region of interest with respect to reference coordinates. The delineated region of interest can be modelled by topographic modelling techniques. A subsequent adequate digital tumour model can facilitate an optimal treatment procedure. The system integrates a diagnostic unit with a therapeutic ultrasonic transmitting component, together with a central processing unit, encompassing algorithms for data processing and visualization. Actual drug uptake is based on passive accumulation of drug carriers. Selective drug release of e.g. cytostatic drugs is achieved by ultrasound induced cavitation well defined to the tumour region. Monitoring of drug release can be achieved by imaging techniques. Measurement and monitoring of cavitational activities within the volume of release, and established functional relationships between cavitation level and drug release, will be bridged to various control functions by the processing unit. Further concurrent thermal treatment approaches and ionizing radiation modi are proposed within the comprehensive treatment model. The described multimodal treatment concept has been converted into an actual patient treatment system, and further elucidated into a concrete algorithm for the therapy of patients. Image guided drug release, mediated by focused ultrasound, within a multimodal treatment framework, may localize the effects to the tumour volume and, therefore, allowing for more aggressive therapy, thus enhancing the therapeutic ratio. Integrated image guided drug release systems will probably increase treatment efficacy and survival rates in the future.

Anti-inflammatory agent indomethacin reduces invasion and alters metabolism in a human breast cancer cell line

Hostile physiological environments such as hypoxia and acidic extracellular pH, which exist in solid tumors, may promote invasion and metastasis through inflammatory responses and formation of eicosanoids. Here, we have investigated the effects of the anti-inflammatory agent indomethacin on the invasion and metabolism of the human breast cancer cell line MDA-MB-435 in Dulbecco's Modified Eagles (DME)-based or Roswell Park Memorial Institute (RPMI)-based cell medium, using a magnetic resonance-compatible invasion assay. Indomethacin treatment significantly reduced the invasion of MDA-MB-435 cells independent of the culture and perfusion conditions examined. Significant changes were detected in levels of intracellular choline phospholipid metabolites and in triglyceride (TG) concentrations of these cells, depending on indomethacin treatment and basal cell medium used. Additionally, genetic profiling of breast cancer cells, grown and treated with low-dose indomethacin in cell culture using an RPMI-based medium, revealed the upregulation of several genes implicating cyclooxygenase-independent targets of indomethacin. These data confirm the ability of an anti-inflammatory agent to reduce breast cancer invasion and demonstrate, depending on cell culture and perfusion conditions, that the indomethacin-induced decrease in invasion is associated with changes in choline phospholipid metabolism, TG metabolism, and gene expression.

Determination of regional brain temperature using proton magnetic resonance spectroscopy to assess brain-body temperature differences in healthy human subjects

Proton magnetic resonance spectroscopy ((1)H MRS) was used to determine brain temperature in healthy volunteers. Partially water-suppressed (1)H MRS data sets were acquired at 3T from four different gray matter (GM)/white matter (WM) volumes. Brain temperatures were determined from the chemical-shift difference between the CH(3) of N-acetyl aspartate (NAA) at 2.01 ppm and water. Brain temperatures in (1)H MRS voxels of 2 x 2 x 2 cm(3) showed no substantial heterogeneity. The volume-averaged temperature from single-voxel spectroscopy was compared with body temperatures obtained from the oral cavity, tympanum, and temporal artery regions. The mean brain parenchyma temperature was 0.5 degrees C cooler than readings obtained from three extra-brain sites (P < 0.01). (1)H MRS imaging (MRSI) data were acquired from a slice encompassing the single-voxel volumes to assess the ability of spectroscopic imaging to determine regional brain temperature within the imaging slice. Brain temperature away from the center of the brain determined by MRSI differed from that obtained by single-voxel MRS in the same brain region, possibly due to a poor line width (LW) in MRSI. The data are discussed in the light of proposed brain-body temperature gradients and the use of (1)H MRSI to monitor brain temperature in pathologies, such as brain trauma.

Measurement of brain temperature with magnetic resonance spectroscopy in acute ischemic stroke

OBJECTIVE

Pyrexia is associated with poor outcome after stroke, but the temperature changes in the brain after stroke are poorly understood. We used magnetic resonance spectroscopic imaging (water-to-N-acetylaspartate frequency shift) to measure cerebral temperature noninvasively in stroke patients.

METHODS

We performed magnetic resonance diffusion, perfusion (diffusion- and perfusion-weighted imaging), and magnetic resonance spectroscopic imaging, compared temperatures in tissues as defined by the diffusion-weighted imaging appearance (definitely abnormal, possibly abnormal and immediately adjacent normal-appearing brain, and normal brain), and tested associations with lesion and patient characteristics.

RESULTS

Among 40 patients, temperature was higher in possibly abnormal (37.63 degrees C) than in definitely abnormal tissue (37.30 degrees C; p < 0.001) or in normal-appearing brain (ipsilateral, 37.16 degrees C; contralateral, 37.22 degrees C; both p < 0.001). Ischemic lesion temperature increased before normal brain temperature. Higher temperatures occurred in lesions that were large, had diffusion/perfusion-weighted imaging mismatch, had reduced cerebral blood flow, and in clinically severe strokes. Only 1 of 25 patients with ischemic lesion temperature greater than 37.5 degrees C was pyrexial.

INTERPRETATION

Temperature is elevated in acutely ischemic brain. More work is required to determine whether raised temperature results from ischemic metabolic reactions, impaired heat exchange from reduced cerebral blood flow, or early inflammatory cell activity (or a combination of these), but magnetic resonance spectroscopic imaging could be used in studies of temperature after brain injury and to monitor interventions.

Measurement of regional brain temperature using proton spectroscopic imaging: validation and application to acute ischemic stroke

A magnetic resonance proton spectroscopic imaging (SI) technique was developed to measure regional brain temperatures in human subjects. The technique was validated in a homogeneous phantom and in four healthy volunteers. Simulations and calculations determined the theoretical measurement precision as approximately +/-0.3 degrees C for individual 1-ml voxels. In healthy volunteers, repeated measurements on individual voxels had an S.D. = 1.2 degrees C. In a clinical study, 40 patients with acute ischemic stroke were imaged within 26 h (mean, 10 h) of onset. Temperatures were highest in the region that appeared abnormal (i.e., ischemic) on diffusion-weighted imaging (DWI) compared with a normal-appearing brain. The mean temperature difference between the DWI "lesion" area and the "normal brain" was 0.17 degrees C [P < 10(-3); range, 2.45 degrees C (hotter)-2.17 degrees C (cooler)]. Noninvasive temperature measurement by SI has sufficient precision to be used in studies of pathophysiology in stroke and in other brain disorders and to monitor therapies.

Sodium ion apparent diffusion coefficient in living rat brain

The apparent diffusion coefficient (ADC) of Na(+) was determined in live rat brain. The brain extracellular-to-intracellular Na(+) content ratio is approximately 8:2, which is the inverse of that for water in these spaces. Consequently, the ADC of Na(+) is primarily affected by motion in the extracellular space, and Na(+) can be viewed as a reporter molecule for motion in that space. Likewise, water ADC is dominated by intracellular motion. The brain Na(+) ADC was 1.15 +/- 0.09 microm(2)/ms, which is 61% of the aqueous Na(+) free diffusion coefficient (D(free)) at 37 degrees C (1.9 microm(2)/ms), while the ADC for brain water is 28% of the water D(free) at 37 degrees C (3 microm(2)/ms). This suggests that the ADC of molecular species within the extracellular space is roughly twofold that within the intracellular space. In postmortem brain, both Na(+) and water decrease to 17% of the respective D(free) values. These results are consistent with Na(+) and water ADC values sharing the same biophysical determinants in postmortem brain. The observed difference between Na(+) and water ADC/D(free) ratios in living brain tissue may be attributable to the extracellular environment hindering molecular displacements twofold less than the intracellular environment.

Disassociation between intracranial and systemic temperatures as an early sign of brain death

Intracranial temperature and its normal variation, as well as its response to various pathologic conditions, has become a critical component of monitoring in neurosurgical intensive care. In a prospective clinical study of 54 neurosurgical patients, intracranial pressure, cerebral perfusion pressure, and intraventricular and systemic temperatures were monitored in a neurosurgical intensive care unit. All of our patients' intraventricular temperatures were initially higher than their systemic temperatures. In 11 patients, the intraventricular temperature became lower than the systemic temperature, in a median time of 4.43 hours (range, 4.21-5.18 hours), prior to any changes in intracranial and cerebral perfusion pressures. Reversal of the disassociation between intraventricular and systemic temperatures may be an early marker of patients with a poor prognosis.

Effective selective head cooling during posthypoxic hypothermia in newborn piglets

Selective head cooling has been proposed as a neuroprotective intervention after hypoxia-ischemia in which the brain is cooled without subjecting the rest of the body to significant hypothermia, thus minimizing adverse systemic effects. There are little data showing it is possible to cool the brain more than the body. We have therefore applied selective head cooling to our hypoxia-ischemia piglet model to establish whether it is possible. Nine piglets were anesthetized, and brain temperature was measured at the surface and in the superficial (0.2 cm) and deep (1.7-2.0 cm) gray matter. Rectal (6-cm depth), skin, and scalp temperatures (T) were recorded continuously. Lowering T-rectal from normothermia (39 degrees C) to hypothermia (33.5-33.8 degrees C) using a head cap perfused with cold (6-24 degrees C) water was undertaken for up to 6 h. To assess the impact of the 45-min hypoxia-ischemia insult on the effectiveness of selective head cooling, four piglets were cooled both before and after the insult, and four, only afterward. During selective head cooling, it was possible to achieve a lower T-deep brain than T-rectal in all animals both before and after hypoxia. However, this was only possible when overhead body heating was used. The T-rectal to T-deep brain gradient was significantly smaller after the insult (median, 5.3 degrees C; range, 4.2-8.5 degrees C versus 3.0 degrees C; 1.7-7.4 degrees C; p = 0.008). During rewarming to normothermia, the gradient was maintained at 4.5 degrees C. We report for the first time a study, which by direct measurement of deep intracerebral temperatures, validates the cooling cap as an effective method of selective brain cooling in a newborn animal hypoxia-ischemia model.

Mitochondrial uncoupling protein 2 (UCP2) in the nonhuman primate brain and pituitary

Energy dissipating mechanisms and their regulatory components represent key elements of metabolism and may offer novel targets in the treatment of metabolic disorders, such as obesity and diabetes. Recent studies have shown that a mitochondrial uncoupling protein (UCP2), which uncouples mitochondrial oxidation from phosphorylation, is expressed in the rodent brain by neurons that are known to regulate autonomic, metabolic, and endocrine processes. To help establish the relevance of these rodent data to primate physiology, we now examined UCP2 messenger RNA and peptide expressions in the brain and pituitary gland of nonhuman primates. In situ hybridization histochemistry showed that UCP2 messenger RNA is expressed in the paraventricular, supraoptic, suprachiasmatic, and arcuate nuclei of the primate hypothalamus and also in the anterior lobe of the pituitary gland. Immunocytochemistry revealed abundant UCP2 expression in cell bodies and axonal processes in the aforementioned nuclei as well as in other hypothalamic and brain stem regions and all parts of the pituitary gland. In the hypothalamus, UCP2 was coexpressed with neuropeptide Y, CRH, oxytocin, and vasopressin. In the pituitary, vasopressin and oxytocin-producing axonal processes in the posterior lobe and POMC cells in the intermediate and anterior lobes expressed UCP2. On the other hand, none of the GH-producing cells of the anterior pituitary was found to produce UCP2. The abundance and distribution pattern of UCP2 in the primate brain and pituitary suggest that this protein is evolutionary conserved and may relate to central autonomic, endocrine and metabolic regulation.

Cooling the newborn after asphyxia - physiological and experimental background and its clinical use

Many years of experimental work on hypoxic-ischaemic injury have supported the hypothesis that cooling the body and brain after the primary injury offers permanent neuroprotection. Clinically, the question of how late cooling can start after the insult and still have a protective effect is important and not fully investigated. Pilot studies in human adults initiated cooling after 10-18 h (trauma, stroke), however animal data suggest cooling is not effective if started later than 6 h. There might be a threshold for 'cooling dose' - by depth or duration - to achieve permanent protection. Hypothermia must be administered with understanding of the extensive physiological effects. Different enzymes have different sensitivity to changes in temperature, hence some effects may be beneficial and some deleterious. Hypothermia and cardiovascular responses and coagulation needs careful monitoring.

Brain uncoupling protein 2: uncoupled neuronal mitochondria predict thermal synapses in homeostatic centers

Distinct brain peptidergic circuits govern peripheral energy homeostasis and related behavior. Here we report that mitochondrial uncoupling protein 2 (UCP2) is expressed discretely in neurons involved in homeostatic regulation. UCP2 protein was associated with the mitochondria of neurons, predominantly in axons and axon terminals. UCP2-producing neurons were found to be the targets of peripheral hormones, including leptin and gonadal steroids, and the presence of UCP2 protein in axonal processes predicted increased local brain mitochondrial uncoupling activity and heat production. In the hypothalamus, perikarya producing corticotropin-releasing factor, vasopressin, oxytocin, and neuropeptide Y also expressed UCP2. Furthermore, axon terminals containing UCP2 innervated diverse hypothalamic neuronal populations. These cells included those producing orexin, melanin-concentrating hormone, and luteinizing hormone-releasing hormone. When c-fos-expressing cells were analyzed in the basal brain after either fasting or cold exposure, it was found that all activated neurons received a robust UCP2 input on their perikarya and proximal dendrites. Thus, our data suggest the novel concept that heat produced by axonal UCP2 modulates neurotransmission in homeostatic centers, thereby coordinating the activity of those brain circuits that regulate daily energy balance and related autonomic and endocrine processes.

Failure of localized head cooling to reduce brain temperature in adult humans

Non-invasive brain temperature measurements using proton magnetic resonance spectroscopy were used to test the hypothesis that localized head cooling would reduce brain temperature in 10 normal adult humans. Temperature reductions of the head surface to 15.8+/-3.5 degrees C did not reduce brain temperature measured in the superficial cortex (36.8+/-0.5 degrees C) or thalamus (36.6+/-0.7 degrees C), as compared to measurements obtained with a head surface temperature of 34.7+/-1.6 degrees C (37.0+/-0.6 degrees C and 36.6+/-0.4 degrees C, respectively). There was no change in the temperature gradient from the superficial to deep brain locations in the presence or absence of head cooling, and brain temperature did not decrease as a function of the duration of head cooling for periods up to 50 min. There was no correlation between the scalp surface (range: 10-38 degrees C) and brain temperature at either the deep or superficial locations.