A model to predict the histopathology of human stroke using diffusion and T2-weighted magnetic resonance imaging

Diffusion tensor imaging of brain development

Understanding early human brain development is of great clinical importance, as many neurological and neurobehavioral disorders have their origin in early structural and functional cerebral organization and maturation. Diffusion tensor imaging (DTI), a recent magnetic resonance (MR) modality which assesses water diffusion in biological tissues at a microstructural level, has revealed a powerful technique to explore the structural basis of normal brain development. In fact, the tissue organization can be probed non-invasively, and the age-related changes of diffusion parameters (mean diffusivity, anisotropy) reveal crucial maturational processes, such as white matter myelination. Nevertheless, the developing human brain presents several challenges for DTI applications compared with the adult brain. DTI may further be used to detect brain injury well before conventional MRI, as water diffusion changes are an early indicator of cellular injury. This is particularly critical in infants in the context of administration of neuroprotective therapies. Changes in diffusion characteristics further provide early evidence of both focal and diffuse white matter injury in association with periventricular leukomalacia in the preterm infant. Finally, with the development of 3D fiber tractography, the maturation of white matter connectivity can be followed throughout infant development into adulthood with the potential to study correlations between abnormalities on DTI and ultimate neurologic/cognitive outcome.

Ischemic cerebral tissue response to subventricular zone cell transplantation measured by iterative self-organizing data analysis technique algorithm

To investigate the changes of the ischemic lesion in rat brain after subventricular zone (SVZ) cell transplantation and the influence of the grafted cells on the appearance of angiogenesis, SVZ cells, superparamagnetically labeled, were intracisternally transplanted into the rat brain 48 h after onset of embolic stroke. A complete set of magnetic resonance (MR) images was acquired for all animals with (n=8) and without (n=3) cell grafting at approximately 24 h, 72 h, and weekly for 6 weeks after stroke. Transplanted cells were tracked by high-resolution three-dimensional gradient-echo images and the interaction between the cells and ischemic lesion was detected by ISODATA (Iterative Self-Organizing Data Analysis Technique Algorithm) calculated from T(1), T(2) and T(1sat) maps. Tissue status from ISODATA was characterized by a specific signature, which represents the deviation from normal tissue in the feature space. Transplanted SVZ cells selectively migrated towards the ischemic side of the rat brain and approached the lesion boundary within 1-week after grafting. Cell treated rats exhibited a significant reduction of average lesion size compared with control rats (P<0.05). A significant reduction of tissue signature (P<0.001) induced by cell transplantation was localized to the position of grafted cells, and these sites exhibited stably restored cerebral blood flow (CBF) (approximately 85% of normal CBF). Angiogenesis was present in sites either immediately adjacent to or surrounded by the grafted cells. Our data indicate that map-ISODATA accurately and dynamically characterizes the ischemic lesion and its response to cell therapy.

MRI detects white matter reorganization after neural progenitor cell treatment of stroke

We evaluated the effects of neural progenitor cell treatment of stroke on white matter reorganization using MRI. Male Wistar rats (n = 26) were subjected to 3 h of middle cerebral artery occlusion and were treated with neural progenitor cells (n = 17) or without treatment (n = 9) and were sacrificed at 5-7 weeks thereafter. MRI measurements revealed that grafted neural progenitor cells selectively migrated towards the ischemic boundary regions. White matter reorganization, confirmed histologically, was coincident with increases of fractional anisotropy (FA, P < 0.01) after stroke in the ischemic recovery regions compared to that in the ischemic core region in both treated and control groups. Immunoreactive staining showed axonal projections emanating from neurons and extruding from the corpus callosum into the ipsilateral striatum bounding the lesion areas after stroke. Fiber tracking (FT) maps derived from diffusion tensor imaging revealed similar orientation patterns to the immunohistological results. Complementary measurements in stroke patients indicated that FT maps exhibit an overall orientation parallel to the lesion boundary. Our data demonstrate that FA and FT identify and characterize cerebral tissue undergoing white matter reorganization after stroke and treatment with neural progenitor cells.

The Evolution of Cerebral Ischemia in a Rat Model of Complete Unilateral Carotid Artery Occlusion With Severe Hypotension as Detected By Diffusion-, T2-, and Postcontrast T1-Weighted Magnetic Resonance Images

Severe internal carotid artery stenosis or occlusion is considered to be one of the important causes of stroke. The authors created a complete unilateral carotid artery occlusion model in 15 Sprague-Dawley rats, induced severe hypotension for at least 36 minutes by exsanguination with the target mean arterial pressure being equal or less than 35 mmHg, and investigated the temporal and spatial evolution of cerebral ischemia by diffusion-, T2-, and postcontrast T1-weighted magnetic resonance images. Cerebral ischemia was detected in most regions of the right middle cerebral artery territory during exsanguination. There was no significant relationship between ischemic lesion volume detected on apparent diffusion coefficient (ADC) map (ADC lesion volume) and infarction volume found on histopathology. However, there was a linear relationship between the change in ADC lesion volume at blood reinfusion (after reinfusion minus before reinfusion) and the enlargement of the lesion volume during the postreinfusion period (Y = 0.4X + 161.7, P = 0.0066) and a significant logarithmic correlation between the volume of vasogenic edema found on postcontrast T1-weighted image at 1 hour of the postreinfusion period and the enlargement of the lesion volume during the postreinfusion period (Y = 62.1 x logX - 115.4, P = 0.022). In conclusion, although it may be difficult to predict the outcome of cerebral ischemia (infarction volume) from the lesion volume during exsanguination, the evolution of cerebral ischemia may be partly predicted by lesion volume changes seen on the ADC maps at the time of the blood reinfusion or by the severity of blood-brain barrier disruption at the early stage of the postreinfusion period.

Statistical prediction of tissue fate in acute ischemic brain injury

An algorithm was developed to statistically predict ischemic tissue fate on a pixel-by-pixel basis. Quantitative high-resolution (200 x 200 microm) cerebral blood flow (CBF) and apparent diffusion coefficient (ADC) were measured on acute stroke rats subjected to permanent middle cerebral artery occlusion and an automated clustering (ISODATA) technique was used to classify ischemic tissue types. Probability and probability density profiles were derived from a training data set (n=6) and probability maps of risk of subsequent infarction were computed in another group of animals (n=6) as ischemia progressed. Predictions were applied to overall tissue fate. Performance measures (sensitivity, specificity, and receiver operating characteristic) showed that prediction made based on combined ADC+CBF data outperformed those based on ADC or CBF data alone. At the optimal operating points, combined ADC+CBF predicted tissue infarction with 86%+/-4% sensitivity and 89%+/-6% specificity. More importantly, probability of infarct (P(I)) for different ISODATA-derived ischemic tissue types were also computed: (1) For the 'normal' cluster in the ischemic right hemisphere, P(I) based on combined ADC+CBF data (P(I)[ADC+CBF]) accurately reflected tissue fate, whereas P(I)[ADC] and P(I)[CBF] overestimated infarct probability. (2) For the 'perfusion-diffusion mismatch' cluster, P(I)[ADC+CBF] accurately predicted tissue fate, whereas P(I)[ADC] underestimated and P(I)[CBF] overestimated infarct probability. (3) For the core cluster, P(I)[ADC+CBF], P(I)[ADC], and P(I)[CBF] prediction were high and similar ( approximately 90%). This study shows an algorithm to statistically predict overall, normal, ischemic core, and 'penumbral' tissue fate using early quantitative perfusion and diffusion information. It is suggested that this approach can be applied to stroke patients in a computationally inexpensive manner.

Isotropic diffusion weighting in radial fast spin-echo magnetic resonance imaging

Radial fast spin-echo (radial-FSE) methods enable multishot diffusion-weighted MRI (DWMRI) to be carried out without significant artifacts due to motion and/or susceptibility and can be used to generate DWMRI images with high spatial resolution. In this work, a novel method that allows isotropic diffusion weighting to be obtained in a single radial k-space data set is presented. This is accomplished by altering the direction of diffusion weighting gradients between groups of TR periods, which yield sets of radial lines that possess diffusion weighting sensitive to motion in different directions. By altering the diffusion weighting directions and controlling the view ordering appropriately within the sequence, an effectively isotropic diffusion-weighted image can be obtained within one radial-FSE scan. The order in which radial lines are acquired can also be controlled to yield data sets without significant artifacts due to motion, T(2) decay, and/or diffusion anisotropy.

Temporal evolution of water diffusion parameters is different in grey and white matter in human ischaemic stroke

OBJECTIVES

Our purpose was to investigate whether differences exist in the values and temporal evolution of mean diffusivity (<D>) and fractional anisotropy (FA) of grey and white matter after human ischaemic stroke.

METHODS

Thirty two patients with lesions affecting both grey and white matter underwent serial diffusion tensor magnetic resonance imaging (DT-MRI) within 24 hours, and at 4-7 days, 10-14 days, 1 month, and 3 months after stroke. Multiple small circular regions of interest (ROI) were placed in the grey and white matter within the lesion and in the contralateral hemisphere. Values of <D>[grey], <D>[white], FA[grey] and FA[white] were measured in these ROI at each time point and the ratios of ischaemic to normal contralateral values (<D>R and FAR) calculated.

RESULTS

<D> and FA showed different patterns of evolution after stroke. After an initial decline, the rate of increase of <D>[grey] was faster than <D>[white] from 4-7 to 10-14 days. FA[white] decreased more rapidly than FA[grey] during the first week, thereafter for both tissue types the FA decreased gradually. However, FA[white] was still higher than FA[grey] at three months indicating that some organised axonal structure remained. This effect was more marked in some patients than in others. <D>R[grey] was significantly higher than <D>R[white] within 24 hours and at 10-14 days (p<0.05), and FAR[white] was significantly more reduced than FAR[grey] at all time points (p<0.001).

CONCLUSIONS

The values and temporal evolution of <D> and FA are different for grey and white matter after human ischaemic stroke. The observation that there is patient-to-patient variability in the degree of white matter structure remaining within the infarct at three months may have implications for predicting patient outcome.

Motor response to amphetamine treatment, task-specific training, and limited motor experience in a postacute animal stroke model

Despite advances in acute treatment of ischemic cerebrovascular events, the most common clinical outcome is disabling neurological impairment. Despite experimental evidence that psychostimulant treatment can positively affect recovery rate after focal brain lesions, beyond rehabilitation therapies there are no currently accepted medical treatments indicated for diminishing neurological impairment after clinically established stroke. To test the effect of amphetamine, task-specific training, limiting motor experience, and their interaction on motor recovery in a postacute animal model of stroke, animals were nonaversively trained in beam walking before a unilateral photochemical sensorimotor cortex lesion and tested for 10 days after lesion. Animals were randomized to groups receiving: a single session of motor training 24 h after lesion; a single injection of amphetamine 2 mg/kg 24 h after lesion; beam-walking experience limited to testing on days 1 and 10 after lesion; and groups that received amphetamine treatment combined with training or combined with limited experience. Motor recovery was maximally enhanced by training, delayed by amphetamine treatment, and most negatively affected by limiting beam-walking experience during the recovery period. These findings support physical training after stroke, indicating that limiting physical activity negatively affects motor recovery and raises questions about the role of stimulant treatment to enhance motor recovery in the postacute phase after stroke.

Microsphere-induced embolic stroke: an MRI study

Despite the many studies of the middle cerebral artery occlusion (MCAO) model, efficient therapy for stroke is still lacking, emphasizing the need for further development and characterization of experimental stroke models. In the present study, the rather unexplored multifocal microsphere-induced stroke model in rats was characterized by multiparametric MRI. We induced microembolic infarction in a group of Sprague-Dawley rats by injecting a dose of about 1000 50-microm polyethylene microspheres intracranially from the external carotid artery. Diffusion-, perfusion-, and T(2)-weighted MRI were used to evaluate the infarct development during and following the first 3 hr after microsphere injection (N = 20). The animals were also imaged at 12-hr (N = 8), 24-hr (N = 17), and 48-hr (N = 5) time points. After the final imaging time point, the brains were removed and sectioned into 2-mm-thick slices, and infarct volumes were measured by 2,3,4-triphenyltetrazolium chloride (TTC) staining. From calculated apparent diffusion coefficient (ADC) maps, a volume of reduced ADC appeared 0.5-1.0 hr postinjection, and by the 3-hr time point the volume of ADC reduction had increased to a size of 5% +/- 1% (mean +/- SEM) of the brain hemisphere. The lesion volume increased significantly (P < 0.01) to 16% +/- 2% of the hemisphere volume at the 12-hr time point, while at 24 hr the lesion (15% +/- 2% of the hemisphere) was also significantly larger (P < 0.001) than at 3 hr. The perfusion deficit resulting from the microsphere injection was immediate, going from a cerebral blood flow index (CBF(i)) of 74% +/- 3% at the time of microsphere injection to 68% +/- 2% of the contralateral mean at 3 hr (P < 0.05), to 55% +/- 4% of the contralateral values at 12 hr (P < 0.05), and to 57% +/- 2% of the contralateral mean at 24 hr (P < 0.001). The lesion development in the microsphere-induced stroke model was found to be slower than in the MCAO model, and continued up to the 24-48-hr time point.

Nuclear magnetic resonance (NMR) measurement of the apparent diffusion coefficient (ADC) of tissue water and its relationship to cell volume changes in pathological states

Diffusion-weighted nuclear magnetic resonance (NMR) imaging (DWI) is sensitive to the random translational motion of water molecules due to Brownian motion. Although the mechanism is still not completely understood, the cellular swelling that accompanies cell membrane depolarization results in a reduction in the net displacement of diffusing water molecules and thus a concomitant reduction in the apparent diffusion coefficient (ADC) of tissue water. Cerebral regions of reduced ADC appear hyperintense in a DWI and this technique has been used extensively to study acute stroke. In addition to cerebral ischemia, reductions in the ADC of cerebral water have been observed following cortical spreading depression, ischemic depolarizations (IDs), transient ischemic attack (TIA), status epilepticus, and hypoglycemia. Although the mechanism responsible for initiating membrane depolarization varies in each case, the ensuing cell volume changes follow a similar pattern. Water ADC values are also affected by the presence and orientation of barriers to translational motion (such as cell membranes and myelin fibers) and thus NMR measures of anisotropic diffusion are sensitive to more chronic pathological states where the integrity of these structures is modified by disease. Both theoretical prediction and experimental evidence suggest that the ADC of tissue water is related to the volume fraction of the interstitial space via the electrical conductivity of the tissue. The implication is that acute neurological disorders that exhibit electrical conductivity changes should also exhibit ADC changes that are detectable by DWI. A qualitative correlation between electrical conductivity and the ADC of water has been demonstrated in a number of animal model studies and the results indicate that reduced ADC values are associated with reductions in the extracellular volume fraction and increased extracellular tortuosity. The close relationship between ADC changes and cell volume changes in various pathological states suggests that NMR measurements are also sensitive to chemical communication between cells through the extracellular space (i.e., extrasynaptic or volume transmission, VT).

MRI measurements of water diffusion: impact of region of interest selection on ischemic quantification

OBJECTIVE

To investigate the effect of ADC heterogeneity on region of interest (ROI) measurement of isotropic and anisotropic water diffusion in acute (< 12 h) cerebral infarctions.

METHODS AND MATERIALS

Full diffusion tensor images were retrospectively analyzed in 32 patients with acute cerebral infarction. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were measured in ischemic lesions and in the corresponding contralateral, normal appearing brain by using four ROIs for each patient. The 2 x 2 pixel square ROIs were placed in the center, the lateral rim and the medial rim of the infarction. In addition, the whole volume of the infarction was measured using a free hand method. Each ROI value obtained from the ischemic lesion was normalized using contralateral normal ROI values.

RESULTS

The localization of the ROIs in relation to the ischemic lesion significantly affected ADC measurement (P < 0.01, using Friedman test), but not FA measurement (P = 0.25). Significant differences were found between ADC values of the center of the infarction versus whole volume (P < 0.01), and medial rim versus whole volume of infarction (P < 0.001) with variation of relative ADC values up to 11%. The differences of absolute ADC for these groups were 22 and 23%, respectively. The lowest ADC was found in the center, followed by medial rim, lateral rim and whole volume of infarction.

CONCLUSION

ADC quantification may provide variable results depending on ROI method. The ADC and FA values, obtained from the center of infarction tend to be lower compared to the periphery. The researchers who try to compare studies or work on ischemic quantification should be aware of these differences and effects.

Dynamic tracking of acute ischemic tissue fates using improved unsupervised ISODATA analysis of high-resolution quantitative perfusion and diffusion data

High-resolution (200 x 200 x 1,500 microm3) imaging was performed to derive quantitative cerebral blood flow (CBF) and apparent diffusion coefficient (ADC) maps in stroke rats (permanent occlusion) every 30 minutes up to 3 hours after occlusion onset, followed by histology at 24 hours. An improved automated iterative-self-organizing-data-analysis-algorithm (ISODATA) was developed to dynamically track ischemic tissue fate on a pixel-by-pixel basis during the acute phase. ISODATA-resolved clusters were overlaid on the CBF-ADC scatterplots and image spaces. Tissue volume ADC, and CBF of each ISODATA cluster were derived. In contrast to the single-cluster normal left hemisphere (ADC = 0.74 +/- 0.02 x 10(-3) mm2/s, CBF = 1.36 +/- 0.22 mL g(-1)min(-1), mean +/- SD, n = 8), the right ischemic hemisphere exhibited three ISODATA clusters, namely: "normal" (normal ADC and CBF), "ischemic core" (low CBF and ADC), and at-risk "perfusion-diffusion mismatch" (low CBF but normal ADC). At 180 minutes, the mismatch disappeared in five rats (Group I, 180-minute "core" lesion volume = 255 +/- 62 mm3 and 24-hour infarct volume = 253 +/- 55 mm3, P > 0.05), while a substantial mismatch persisted in three rats (Group II, 180-minute CBF-abnormal volume = 198 +/- 7 mm3 and 24-hour infarct volume 148 +/- 18 mm3, P < 0.05). The CBF (0.3 +/- 0.09 mL g(-1)min(-1)) of the "persistent mismatch" (Group II, 0.3 +/- 0.09 mL g(-1)min(-1)) was above the CBF viability threshold (0.2 to 0.3 mL g(-1)min(-1)) throughout and its ADC (0.70 +/- 0.03 x 10(-3) mm2/s) did not decrease as ischemia progressed. In contrast, the CBF (0.08 +/- 0.03 mL g(-1)min(-1)) of the analogous brain region in Group I was below the CBF viability threshold, and its ADC gradually decreased from 0.63 +/- 0.05 to 0.43 +/- 0.03 x 10(-3) mm2/s (ADC viability threshold = 0.53 +/- 0.02 x 10(-3) mm2/s). The modified ISODATA analysis of the ADC and CBF tissue characteristics during the acute phase could provide a useful and unbiased means to characterize and predict tissue fates in ischemic brain injury and to monitor therapeutic intervention.

Pixel-by-pixel spatiotemporal progression of focal ischemia derived using quantitative perfusion and diffusion imaging

Pixel-by-pixel spatiotemporal progression of focal ischemia (permanent occlusion) in rats was investigated using quantitative perfusion and diffusion magnetic resonance imaging every 30 minutes for 3 hours. The normal left-hemisphere apparent diffusion coefficient (ADC) was 0.76 +/- 0.03 x 10(-3) mm(2)/s and CBF was 0.7 +/- 0.3 mL x g(-1) x min(-1) (mean +/- SD, n=5). The ADC and CBF viability thresholds yielding the lesion volumes (LV) at 3 hours that best approximated the 2,3,5-triphenyltetrazolium chloride (TTC) infarct volumes (200 +/- 30 mm(3)) at 24 hours were 0.53 +/- 0.02 x 10(-3) mm(2)/s (30% +/- 2% reduction) and 0.30 +/- 0.09 mL x g(-1) x min(-1) (57% +/- 11% reduction), respectively. Temporal evolution of the ADC- and CBF-defined LV showed a significant "perfusion-diffusion mismatch" up to 2 hours (P < 0.05, n = 11), a potential therapeutic window. Based on the viability thresholds, three pixel clusters were identified on the CBF-ADC scatterplots: (1) a "normal" cluster with normal CBF and ADC, (2) an "ischemic core" cluster with markedly reduced CBF and ADC, and (3) a "mismatch" cluster with reduced CBF but slightly reduced ADC. These clusters were color-coded and mapped onto the image and CBF-ADC spaces. Lesions grew peripheral and medial to the initial ADC abnormality. In contrast to the CBF distribution, the ADC distribution in the ischemic hemisphere was bimodal; the relatively time-invariant bimodal-ADC minima were 0.57 +/- 0.02 x 10(-3) mm(2)/s (corresponding CBF 0.35 +/- 0.04 mL x g(-1) x min(-1)), surprisingly similar to the TTC-derived thresholds. Together, these results illustrate an analysis approach to systemically track the pixel-by-pixel spatiotemporal progression of acute ischemic brain injury.

Navigated diffusion-weighted imaging with interpolated phase-correction for high-resolution imaging of stroke

Stroke imaging was revolutionised with the introduction of diffusion-weighted MRI (DWI). The commonly used echoplanar DWI suffers from geometrical distortion near the skull base and the frontal regions and from reduced spatial resolution and fat suppression. To allow a voxel-by-voxel comparison between high-resolution spin-echo images, we implemented spin-echo-based DWI. Motion artefacts were eliminated by phase correction in hybrid frequency-Fourier domain using navigator echoes. In a novel approach, distorted navigator echoes which did not eliminate motion artefacts were replaced with interpolated navigator echoes, leading to restored image information. Navigated DWI yielded high-resolution images in 21 of 24 patients with brain ischaemia, allowing diagnosis of even small or diffuse zones of ischaemia. We determined the spatial distribution and mean of T(2)- and DWI signal intensity and apparent diffusion coefficients (ADC), using a multidimensional histogram-based analysis. Mean ADC were decreased in ischaemic areas less than 9 days old. The technique may also be useful for high-resolution DWI of tissue other than the brain.

Remodeling of cardiac fiber structure after infarction in rats quantified with diffusion tensor MRI

Structural remodeling of myocardium after infarction plays a critical role in functional adaptation. Diffusion tensor magnetic resonance imaging (DTMRI) provides a means for rapid and nondestructive characterization of the three-dimensional fiber architecture of cardiac tissues. In this study, microscopic structural changes caused by MI were evaluated in Fischer 344 rats 4 wk after infarct surgery. DTMRI studies were performed on 15 excised, formalin-fixed rat hearts of both infarct (left anterior descending coronary artery occlusion, n = 8) and control (sham, n = 7) rats. Infarct myocardium exhibited increased water diffusivity (41% increase in trace values) and decreased diffusion anisotropy (37% decrease in relative anisotropy index). The reduced diffusion anisotropy correlated negatively with microscopic fiber disarray determined by histological analysis (R = 0.81). Transmural courses of fiber orientation angles in infarct zones were similar to those of normal myocardium. However, regional angular deviation of the diffusion tensor increased significantly in the infarct myocardium and correlated strongly with microscopic fiber disarray (R = 0.86). These results suggest that DTMRI may provide a valuable tool for defining structural remodeling in diseased myocardium at the cellular and tissue level.

MRI tissue characterization of experimental cerebral ischemia in rat

PURPOSE

To extend the ISODATA image segmentation method to characterize tissue damage in stroke, by generating an MRI score for each tissue that corresponds to its histological damage.

MATERIALS AND METHODS

After preprocessing and segmentation (using ISODATA clustering), the proposed method scores tissue regions between 1 and 100. Score 1 is assigned to normal brain matter (white or gray matter), and score 100 to cerebrospinal fluid (CSF). Lesion zones are assigned a score based on their relative levels of similarities to normal brain matter and CSF. To evaluate the method, 15 rats were imaged by a 7T MRI system at one of three time points (acute, subacute, chronic) after MCA occlusion. Then they were killed and their brains were sliced and prepared for histological studies. MRI of two or three slices of each rat brain (using two DWI (b = 400, b = 800), one PDWI, one T2WI, and one T1WI) was performed, and an MRI score between 1 and 100 was determined for each region. Segmented regions were mapped onto the histology images and scored on a scale of 1-10 by an experienced pathologist. The MRI scores were validated by comparison with histology scores. To this end, correlation coefficients between the two scores (MRI and histology) were determined.

RESULTS

Experimental results showed excellent correlations between MRI and histology scores at different time points. Depending on the reference tissue (gray matter or white matter) used in the standardization, the correlation coefficients ranged from 0.73 (P < 0.0001) to 0.78 (P < 0.0001) using the entire dataset, including acute, subacute, and chronic time points. This suggests that the proposed multiparametric approach accurately identified and characterized ischemic tissue in a rat model of cerebral ischemia at different stages of stroke evolution.

CONCLUSION

The proposed approach scores tissue regions and characterizes them using unsupervised clustering and multiparametric image analysis techniques. The method can be used for a variety of applications in the field of computer-aided diagnosis and treatment, including evaluation of response to treatment. For example, volume changes for different zones of the lesion over time (e.g., tissue recovery) can be evaluated.

Non-invasive imaging methods for the characterization of the pathophysiology of brain ischemia

Non-invasive imaging methods are increasingly used to study the evolution and therapy of brain diseases under both clinical and experimental conditions. In the animal experiment, these methods can be supplemented by invasive tissue assays to allow precise characterization of the underlying pathophysiology. Based on such an approach, this review evaluates the importance of in vivo nuclear magnetic resonance (NMR) and positron emission tomography (PET) for the understanding of the pathophysiology of brain ischemia.

Feature-based, automated segmentation of cerebral infarct patterns using T2- and diffusion-weighted imaging

Diffusion-weighted imaging enables the diagnosis of cerebral ischemias very early, thus supporting therapies such as thrombolysis. However, morphology and tissue-characterizing parameters (e.g. relaxation times or water diffusion) may vary strongly in ischemic regions, indicating different underlying pathologic processes. As the determination of the parameters by a supervised segmentation is very time consuming, we evaluated whether different infarct patterns may be segmented by an automated, multidimensional feature-based method using a unified segmentation procedure. Ischemias were classified into 5 characteristic patterns. For each class, a 3D histogram based on T(2)- and diffusion-weighted images as well as calculated apparent diffusion coefficients (ADC) was generated from a representative data set. Healthy and pathologic tissue classes were segmented in the histogram as separate, local density maxima with freely shaped borders. Segmentation control parameters were optimized in a 3-step procedure. The method was evaluated using synthetic images as well as results of a supervised segmentation. For the analysis of cerebral ischemias, the optimal control parameter set led to sensitivities and specificities between 1.0 and 0.9.

Diffusion tensor imaging of normal and injured developing human brain - a technical review

The application of diffusion tensor imaging (DTI) to the evaluation of developing brain remains an area of active investigation. This review focuses on the changes in DTI parameters which accompany both brain maturation and injury. The two primary pieces of information available from DTI studies-water apparent diffusion coefficient and diffusion anisotropy measures-change dramatically during development, reflecting underlying changes in tissue water content and cytoarchitecture. DTI parameters also change in response to brain injury. In this context, not only does DTI offer the possibility of detecting injury earlier than conventional imaging methods, but also appears more sensitive to disruption of white matter than any other imaging method. DTI offers unique insight into brain injury and maturation, and does so in a fashion that can be readily applied in a clinical setting.

The role of diffusion tensor imaging in the evaluation of ischemic brain injury - a review

Water diffusion in brain tissue is affected by the presence of barriers to translational motion such as cell membranes and myelin fibers. The measured water apparent diffusion coefficient (ADC) value is therefore frequently anisotropic and varies depending upon the orientation of restricting barriers (such as white matter tracts) relative to the diffusion-sensitive-gradient direction. Anisotropic water diffusion can be specified using indices of diffusion anisotropy [e.g. standard deviation of the individual ADC values, fractional anisotropy (FA), lattice index (LI)], which are derived from measurements of the full diffusion tensor. The rotationally invariant nature of particular diffusion anisotropy indices (e.g. FA, LI) allows orientation-independent comparisons of these parameters between different subjects. Pathophysiological processes (such as cerebral ischemia) that modify the integrity of the tissue microstructure result in significant alterations in tissue anisotropy and make this metric a useful endpoint for characterizing the temporal evolution of the disease. Diffusion-tensor imaging (DTI) studies of both experimental and human stroke suggest that DTI may provide additional information about the evolution of the disease that is not available from diffusion-weighted MRI (DWI) alone. Acute reductions in the average diffusivity [<D> = (lambda(1) + lambda(2) + lambda(3))/3 where lambda(1), lambda(2), and lambda(3) are the eigenvalues of the diffusion tensor] following the onset of cerebral ischemia are often accompanied by increases in diffusion anisotropy. In the transition from acute to sub-acute and chronic stroke, <D> renormalizes and subsequently increases whereas diffusion anisotropy measures (e.g. FA) decline and remained reduced in chronic infarcts. Overall isotropic ADC changes during infarct evolution have been observed to be greater in white matter (WM) than in gray matter (GM) lesions (although there have been conflicting reports on this issue) and GM lesions tend to renormalize prior to WM lesions as the infarct evolves. Ischemic WM exhibits a significant decrease in diffusion anisotropy (relative to normal WM) during ischemic evolution whereas that of ischemic GM remains statistically unchanged. Furthermore, the percentage decrease in ischemic WM <D> is largely determined by reductions in lambda(1), the eigenvalue that coincides with the long axis of the WM fiber tract. Variations in unidirectional ADC or <D> over the ischemic time course limit the usefulness of this parameter alone as a predictor of ischemic injury. Consequently, ADC information has been combined with that of other MR parameters (including DTI) to unambiguously stage and predict ischemic brain injury over its entire temporal evolution. Combined <D> and diffusion anisotropy measurements have identified three phases of diffusion abnormality: (1) reduced <D> and elevated anisotropy; (2) reduced <D> and reduced anisotropy; and (3) elevated <D> and reduced anisotropy. However, variations in the differential patterns of <D> and diffusion anisotropy evolution have been observed by a number of investigators and more work is needed to clarify the role of these measurements in characterizing the severity of the ischemic insult as well as the potential outcome in response to the initial ischemic injury. The use of DTI, in combination with more sophisticated analysis methods for performing multiparametric segmentation, such as multispectral analysis, may enhance the use of MRI for accurate diagnosis and prognosis of stroke. Furthermore, these techniques may also play an important role in the clinical evaluation of new stroke treatments.

Final infarct size after acute stroke: prediction with flow heterogeneity

PURPOSE

To compare acute measurements of flow heterogeneity (FH) and mean transit time (MTT) with follow-up data to determine which method yields better predictive measures of final infarct volumes.

MATERIALS AND METHODS

Twenty-three patients with symptoms of stroke underwent magnetic resonance (MR) imaging during the acute stage, and the tissue at risk was estimated from MTT maps and maps generated by means of detecting abnormal FH. Final infarct volumes were calculated from T2-weighted follow-up MR image measurement. The Wilcoxon signed rank test was performed to compare the two predictive maps (MTT and FH) with T2-weighted follow-up maps.

RESULTS

Eleven (48%) patients experienced infarct growth. Both the MTT and the FH maps enabled prediction of 10 of these cases. There were five false-positive cases with MTT measurement but three with FH measurement. In terms of predicting final infarct volumes, the final infarct size on the MTT maps was overestimated by 75%. The final infarct size on the FH maps also was overestimated, but by only 15%. MTT map measurements were significantly different from follow-up MR image measurements (P =.005), but FH map measurements were not (P =.059).

CONCLUSION

FH maps may enable more precise prediction of final infarct volume in stroke patients.

Cerebral spinal fluid contamination of the measurement of the apparent diffusion coefficient of water in acute stroke

The measurement of the apparent diffusion coefficient (ADC) of water in brains of stroke patients is used in models developed to help distinguish reversible from irreversible ischemic injury. The ADC by conventional methods may be overestimated by the presence of cerebral spinal fluid (CSF) in sulci and perivascular spaces. In this study the hypothesis that DWI with CSF suppression (FLAIR-DWI) would result in different ADC values than those obtained with the conventional DWI technique was investigated. Thirty-one patients with stroke onset of less than 6 hr and an acute lesion on conventional DWI were studied. Both conventional isotropic DWI and FLAIR-DWI were performed using a single-shot echo-planar technique. In all 31 patients, CSF-suppressed ADC was lower than conventional ADC. The mean (SD) of the 31 patients' lesion ADC was 0.64 (0.08) x 10(-3) mm(2) s(-1) with FLAIR-DWI and 0.72 (0.09) x 10(-3) mm(2) s(-1) with conventional DWI (P < 0.001). The overestimation of ADC in conventional DWI corresponded to the percentage of the voxel that contained CSF. Suppression of CSF leads to lesion ADC values that are more homogeneous and more than 15% lower than those obtained with conventional DWI techniques. This suggests that FLAIR-DWI ADC measurements are more accurate than conventional ADC maps.

Progression of neuronal damage after status epilepticus and during spontaneous seizures in a rat model of temporal lobe epilepsy

The present study was designed to address the question of whether recurrent spontaneous seizures cause progressive neuronal damage in the brain. Epileptogenesis was triggered by status epilepticus (SE) induced by electrically stimulating the amygdala in rat. Spontaneous seizures were continuously monitored by video-EEG for up to 6 months. The progression of damage in individual rats was assessed with serial magnetic resonance imaging (MRI) by quantifying the markers of neuronal damage (T2, T1 rho, and Dav) in the amygdala and hippocampus. The data indicate that SE induces structural alterations in the amygdala and the septal hippocampus that progressively increased for approximately 3 weeks after SE. T2, T1 rho, and Dav did not normalize during the 50 days of follow-up after SE, suggesting ongoing neuronal death due to spontaneous seizures. Consistent with these observations, Fluoro-Jade B-stained preparations revealed damaged neurons in the hippocampus of spontaneously seizing animals that were sacrificed up to 62 days after SE. The presence of Fluoro-Jade B-positive neurons did not, however, correlate with the number of spontaneous seizures, but rather with the time interval from SE to perfusion. Further, there were no Fluoro-Jade B-positive neurons in frequently seizing rats that were perfused for histology 6 months after SE. Also, the number of lifetime seizures did not correlate with the severity of neuronal loss in the hilus of the dentate gyrus assessed by stereologic cell counting. The methodology used in the present experiments did not demonstrate a clear association between the number or occurrence of spontaneous seizures and the severity of hilar cell death. The ongoing hippocampal damage in these epileptic animals detected even 2 month after SE was associated with epileptogenic insult, that is, SE rather than spontaneous seizures.

CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department

PURPOSE

To compare the diagnostic accuracy of computed tomography (CT) and magnetic resonance (MR) imaging in a consecutive series of patients at presentation to the emergency department with symptoms of acute stroke.

MATERIALS AND METHODS

Clinical data and images obtained in 691 consecutive patients with suspected acute stroke were examined. Results of first and second head CT and brain diffusion-weighted (DW) and conventional MR imaging were compared with each other and with the final neurologic discharge diagnosis.

RESULTS

Five hundred seventy-three patients underwent CT at presentation, with 42% sensitivity (95% CI: 37%, 46%) and 91% specificity (95% CI: 82%, 96%). A total of 173 patients underwent a second CT examination, with 77% sensitivity (95% CI: 70%, 84%) and 79% specificity (95% CI: 49%, 95%). Of 498 MR images, 411 were DW, with 94% sensitivity (95% CI: 1%, 96%) and 97% specificity (95% CI: 88%, 100%), and 87 were conventional, with 70% sensitivity (95% CI: 58%, 81%) and 94% specificity (95% CI: 70%, 100%). By using DW MR imaging in the early period (<6 hours after presentation to emergency department), a 97% sensitivity (95% CI: 92%, 100%) and a 100% specificity (95% CI: 69%, 100%) were achieved, compared with 58% (29%-84%) and 100% (16%-100%), respectively, with conventional MR imaging, and 40% (35%-45%) and 92% (84%-97%), respectively, with CT. Negative predictive value was higher with DW MR imaging (73%) than with conventional (42%) MR imaging or CT (24%). In studies conducted within 12 hours, DW MR imaging achieved substantially superior accuracy than did CT. After 12 hours, accuracy was equivalent.

CONCLUSION

In the diagnosis of stroke in the early period (<12 hours after presentation), DW MR imaging is superior to conventional MR imaging and CT.

MR microscopy and high resolution small animal MRI: applications in neuroscience research

The application of magnetic resonance (MR) imaging in the study of human disease using small animals has steadily evolved over the past two decades and strongly established the fields of "small animal MR imaging" and "MR microscopy." An increasing number of neuroscience related investigations now implement MR microscopy in their experiments. Research areas of growth pertaining to MR microscopy studies are focused on (1). phenotyping of genetically engineered mice models of human neurological diseases and (2). rodent brain atlases. MR microscopy can be performed in vitro on tissue specimens, ex vivo on brain slice preparations and in vivo (typically on rodents). Like most new imaging technologies, MR microscopy is technologically demanding and requires broad expertise. Uniform guidelines or "standards" of a given MR microscopy experiment are non-existent. The main focus therefore of this review will be on biological applications of MR microscopy and the experimental requirements. We also take a critical look at the biological information that small animal (rodent) MR imaging has provided in neuroscience research.

Quantitative T(1rho) and magnetization transfer magnetic resonance imaging of acute cerebral ischemia in the rat

It has been previously shown that T1 in the rotating frame (T(1rho)) is a very sensitive and early marker of cerebral ischemia and that, interestingly, it can provide prognostic information about the degree of subsequent neuronal damage. In the present study the authors have quantified T(1rho) together with the rate and other variables of magnetization transfer (MT) associated with spin interactions between the bulk and semisolid macromolecular pools by means of Z spectroscopy, to examine the possible overlap of mechanisms affecting these magnetic resonance imaging contrasts. Substantial prolongation of cerebral T(1rho) was observed minutes after induction of ischemia, this change progressing in a time-dependent manner. Difference Z spectra (contralateral nonischemic minus ischemic brain tissue) showed a significant positive reminder in the time points from 0.5 to 3 hours after induction of ischemia, the polarity of this change reversing by 24 hours. Detailed analysis of the MT variables showed that the initial Z spectral changes were due to concerted increase in the maximal MT (+3%) and amount of MT (+4%). Interestingly, the MT rates derived either from the entire frequency range of Z spectra or the time constant for the first-order forward exchange (k(sat)) were unchanged at this time, these variables reducing only one day after induction of ischemia. The authors conclude that T(1rho) changes in the acute phase of ischemia coincide with both elevated maximal MT and amount of MT. These changes occur independent of the overall MT rate and in the absence of net water gain to the tissue, whereas in the consolidating infarction the decrease in the rate and amount of MT, as well as the extensive prolongation of T(1rho), are associated with water accumulation.

Diffusion- and perfusion-weighted MR imaging in a patient with acute demyelinating encephalomyelitis (ADEM)

To monitor changes of brain tissue metabolism in acute demyelinating encephalitis (ADEM), we examined a patient with suspected ADEM by serial MRI including diffusion- and perfusion-weighted imaging (DWI, PWI). Within the inflammatory tissue, the apparent diffusion coefficients were reduced, normal, and increased. Perfusion varied between reduced and normal values, except for small hyperperfused regions. Combining standard MRI with DWI and PWI may elucidate different overlapping phases in cerebral inflammation.

Assessment of brain tissue viability in acute ischemic stroke by BOLD MRI

The introduction of new neuroprotective treatment strategies for acute stroke patients has provided a requirement for neuroimaging methods capable of identifying salvageable tissue in acute stroke patients. Substantial positron emission tomography evidence points to the fact that a peri-infarct zone with blood flow of 20-45% of normal, metabolic rate of oxygen of >35% of normal and oxygen extraction ratio (OER) of >0.7 are indices of tissue at risk of infarction, yet with potential for recovery. The sensitivity of T(2) to blood oxygen level dependent (BOLD) effects allows the mismatch between oxygen delivery and consumption in the brain to be imaged. Previous evidence from animal models of cerebral hypoperfusion and ischemic stroke strongly suggest that T(2) BOLD MRI highlights viable and salvageable brain regions. The Hahn-echo T(2) and diffusion show distinct flow thresholds in the rat brain so that the former parameter probes areas with high OER and the latter genuine ischemia. In the flow-compromised tissue showing negative T(2) BOLD, substantial residual perfusion is evident as revealed by bolus-tracking perfusion MRI, in agreement with the idea that tissue metabolic viability must be preserved for expression of BOLD. It is concluded that BOLD MRI may have potential for the assessment of tissue viability in acute ischemic stroke.

Time course of cerebral infarction in the middle cerebral arterial territory: deep watershed versus territorial subtypes on diffusion-weighted MR images

PURPOSE

To examine possible differences between the evolution of cerebral watershed infarction (WI) and that of territorial thromboembolic infarction (TI) by using diffusion-weighted (DW) and T2-weighted magnetic resonance (MR) images and apparent diffusion coefficient (ADC) maps.

MATERIALS AND METHODS

Fourteen patients with TI and nine with WI underwent MR imaging from the acute to chronic infarction stages. ADC maps were derived from DW images. Lesion-to-normal tissue signal intensity ratios on ADC maps (rADC), echo-planar T2-weighted images, and DW images were calculated. Lesion volumes at acute or early subacute infarction stages were measured on DW images, and final lesion volumes were estimated on fluid-attenuated inversion-recovery images.

RESULTS

Analysis of variance revealed a significant difference in temporal evolution patterns of rADC between WI and TI (P <.001). rADC pseudonormalization following TI began about 10 days after symptom onset, but that following WI did not occur until about 1 month after symptom onset. The Pearson correlation coefficient between final and initial infarct volumes was 0.9899 for both infarction subtypes, indicating that the initial ischemic injury volume measured at the acute or early subacute stage predicted the final lesion volume fairly well.

CONCLUSION

The evolution time of ADC is faster for TI than for WI. This difference, which likely originates from the different pathophysiologic and hemodynamic features of the two infarction types, might account for the relatively large range of ADC values reported for the time course of ischemic strokes.

Ischemic stroke: effects of etiology and patient age on the time course of the core apparent diffusion coefficient

PURPOSE

To determine whether the evolution of the core apparent diffusion coefficient (ADC) of water in ischemic stroke varies with patient age or infarct etiology.

MATERIALS AND METHODS

One hundred forty-seven patients with stroke underwent 236 diffusion-weighted magnetic resonance imaging examinations. Etiologies of lesions were classified according to predefined criteria; in 224 images, the diagnosis of lacune could be firmly established or excluded. ADC was measured in the center of each lesion and in contralateral normal-appearing brain. A model was used to describe the time course of relative ADC (rADC), which is calculated by dividing the lesion ADC by the contralateral ADC, and to test for age- or etiology-related differences in this time course.

RESULTS

Transition from decreasing to increasing rADC was estimated at 18.5 hours after stroke onset. In subgroup analysis, transition was earlier in nonlacunes than in lacunes (P =.02). There was a trend toward earlier transition in patients older than the median age of 66.0 years, compared with younger patients (P =.06). Pseudonormalization was estimated at 216 hours. Among nonlacunes, the rate of subsequent rADC increase was more rapid in younger patients than in older patients (P =.001). Within the smaller sample of lacunes, however, no significant age-related difference in this rate was found.

CONCLUSION

Differences in ADC depending on the patient's age and infarct etiology suggest differing rates of ADC progression.

Diffusion-weighted magnetic resonance imaging detects early neuropathology following four vessel occlusion ischemia in the rat

Early neuropathology following a prolonged duration of four-vessel occlusion (4 VO) ischemia in the rat was charted using magnetic resonance imaging (MRI). Animals received either 30 minutes of 4 VO (N = 6) or sham operation (N = 6) prior to in vivo assessment. Proton density and T(2) and combined T(2)/diffusion-weighted (T(2)/DW) MRI were performed at 6, 24, and 72 hours postocclusion. T(2)/DW imaging was the most effective sequence for delineating between injured and intact tissues, indicating neuropathology in the dorsolateral striatum at 24 hours and in the CA1/CA2 subfields of the hippocampus at 72 hours following ischemia. Apparent diffusion coefficient values were significantly reduced in the striatum (P = 0.03) and hippocampus (P = 0.005) at 24 and 72 hours, respectively. This is the first report, to our knowledge, of T(2)/DW imaging detecting lesions following 4 VO in accord with the known temporal evolution of ischemic brain damage.

Evolution of cerebral ischaemia induced by thromboembolism in rats detected by early sequential MR imaging

Thromboembolic stroke appears to evolve in patients in a very complicated manner. The present study investigated the evolution of thromboembolic stroke in rats (n=9) using a 4.7-T MR imager. Under isoflurane anaesthesia, the rats received homologous blood clots into the right internal carotid artery. After thromboembolic stroke, lesion volume, which was defined and calculated, based on apparent diffusion coefficient maps, tended to increase gradually over the 6 h magnetic resonance imaging study. The largest percentage change in lesion volume was found at the early stage (40-100 min) of thromboembolism, and showed significant correlation with total percentage change in lesion volume (41.6 (SD 32.8%)) (r=0.77, P<0.05). In conclusion, marked enlargement or diminution of lesion volume may be observed at the early stage of thromboembolism. Thromboembolic stroke, which can be partly salvaged at the early stage, may likely evolve to a lesser extent thereafter.

Nonaccidental pediatric head injury: diffusion-weighted imaging findings

OBJECTIVE

Diffusion-weighted imaging (DWI) reveals nonhemorrhagic posttraumatic infarction hours to days before conventional computed tomographic scanning or magnetic resonance imaging (MRI). We evaluated the diagnostic utility of DWI in children with nonaccidental head trauma.

METHODS

The medical records and imaging examinations obtained between January 1998 and May 2000 for all children less than 2 years of age with presumed or suspected nonaccidental head injury were reviewed retrospectively. Twenty children who had undergone DWI within 5 days of presentation were included in the study. Computed tomographic scans, conventional MRI sequences, and DWI combined with apparent diffusion coefficient (ADC) maps were evaluated.

RESULTS

Eleven girls and nine boys (median age, 5 mo) were studied. Eighteen children had presumed nonaccidental head trauma, and two children had suspected nonaccidental head trauma. Of the 18 children with presumed nonaccidental trauma, 16 (89%) demonstrated abnormalities on DWI/ADC, as compared with neither of the two children with suspected nonaccidental trauma. In 13 (81%) of 16 positive cases, DWI revealed more extensive brain injury than was demonstrated on conventional MRI sequences or showed injuries not observed on conventional MRI. DWI combined with ADC maps allowed better delineation of the extent of white matter injury. DWI/ADC abnormalities in the nonaccidental head-injured children were likely to involve posterior aspects of the cerebral hemispheres, with relative sparing of the frontal and temporal poles. Severity on DWI correlated significantly with poor outcome (P < 0.005).

CONCLUSION

DWI has broad applications in the early detection of infarction in children with nonaccidental head injury and enhances the sensitivity of conventional MRI. In the patients in this study, early DWI provided an indicator of severity that was more complete than any other imaging modality. The use of DWI may help to identify children at high risk for poor outcome and to guide management decisions.

MRI analysis of the changes in apparent water diffusion coefficient, T(2) relaxation time, and cerebral blood flow and volume in the temporal evolution of cerebral infarction following permanent middle cerebral artery occlusion in rats

Detailed knowledge of similarities and differences between animal models and human stroke is decisive for selecting clinically effective drugs based on efficacy data obtained preclinically. Differences in the temporal evolution of stroke pathologies between animal models and man have been reported. In view of the importance of this issue for the development of neuroprotective treatments, the temporal evolution of stroke pathologies in the rat permanent middle cerebral artery occlusion (pMCAO) model has been evaluated with magnetic resonance imaging modalities under experimental conditions matching as close as possible those used in humans. Changes in the ipsilateral and contralateral cortex and striatum of cerebral blood flow (CBF) and volume (CBV), apparent diffusion coefficient (ADC), and spin-spin relaxation time (T(2)), as well as total cortical and striatal infarct volumes, calculated from CBF, ADC, and T(2) maps, were determined starting 1 h up to 216 h post-pMCAO. The temporal evolution of the MRI parameters in this rat model was similar to that observed in humans. In particular, the ADC values were decreased for more than 3 days and returned back to baseline between 4 to 8 days, to increase by day 9 only. Thus the stroke pathology in this rat model develops at a similar pace as in stroke patients arguing against a fundamental difference in the mechanisms involved. The infarct volumes however develop differently in this rat model as they invariably increase over the first 48 h, while in humans the evolution of infarct volume is slower and more heterogeneous.

Apparent diffusion coefficient decreases and magnetic resonance imaging perfusion parameters are associated in ischemic tissue of acute stroke patients

Perfusion-and diffusion-weighted magnetic resonance imaging scans are thought to allow the characterization of tissue at risk of infarction. The authors tested the hypothesis that the apparent diffusion coefficient (ADC) decrease should be associated with the severity of the perfusion deficit in ischemic tissue of acute stroke patients. Perfusion-and diffusion-weighted scans were performed in 11 patients with sudden onset of neurologic deficits within the last 6 hours and T2-weighted magnetic resonance imaging scans were obtained after 6 days. Parameter images of the maximum of the contrast agent concentration, time to peak, relative cerebral blood volume, relative cerebral blood flow, and relative mean transit time were computed from the perfusion-weighted data. A threshold function was used to identify tissue volumes with stepwise ADC decreases. An onionlike distribution of successively decreasing ADC values was found, with the lowest ADC in the center of the ischemic region. Correspondingly, tissue perfusion decreased progressively from the periphery toward the ischemic core. This effect was most pronounced in the time-to-peak maps, with a linear association between ADC decrease and time-to-peak increase. Apparent diffusion coefficient values decreased from the periphery toward the ischemic core, and this distribution of ADC values was strongly associated with the severity of the perfusion deficit.

Use of exponential diffusion imaging to determine the age of ischemic infarcts

OBJECTIVE

Diffusion-weighted magnetic resonance imaging (DWI) detects acute ischemic infarcts with high lesion conspicuity. Determination of infarct age is difficult on DWI alone because infarct signal intensity (SIinfarct) on DWI is influenced by T2 properties ("T2 shine-through"). Maps of the apparent diffusion coefficient (ADC) reflect pure diffusion characteristics without T2 effects but have low lesion conspicuity. Thus, in clinical practice, combined use of DWI and ADC maps is required. Exponential DWI (eDWI) is an innovative means of MRI-diffusion data analysis that merges the advantages of DWI and ADC maps. The authors hypothesized that SIinfarct on eDWI would correlate with infarct age. The authors studied 114 consecutive patients who had 120 ischemic strokes with clearly determined onset times and who underwent echo-planar DWI. The eDWI were generated by dividing the signal intensity on DWI by that on the corresponding T2 image on a pixel-by-pixel basis. SIinfarct on eDWI was measured in the lesion core and expressed as a percentage of contralateral control tissue. On eDWI, relative SIinfarct changed significantly with infarct age (P < .0001). When patients were sorted in infarct-age groups, no significant differences were found within the first 120 hours. However, for patients studied within 5 days, the mean relative SIinfarct was significantly higher compared with patients studied > or = 8 days after stroke (P < .05). For all infarcts up to 5 days old, the eDWI signal intensity was higher than control tissue (hyperintense appearance). All infarcts > 10 days old had an eDWI signal intensity lower than control tissue (hypointense appearance). The authors concluded that the use of eDWI, as a single set of images, reliably differentiates acute infarcts (< or = 5 days old) from infarcts > 10 days old. This feature would be expected to be helpful when the distinction between acute and nonacute infarction cannot be determined on clinical grounds.

Use of spin echo T(2) BOLD in assessment of cerebral misery perfusion at 1.5 T

Inadequate blood supply relative to metabolic demand, a haemodynamic condition termed as misery perfusion, often occurs in conjunction with acute ischaemic stroke. Misery perfusion results in adaptive changes in cerebral physiology including increased cerebral blood volume (CBV) and oxygen extraction ratio (OER) to secure substrate supply for the brain. It has been suggested that the presence of misery perfusion may be an indication of reversible ischaemia, thus detection of this condition may have clinical impact in acute stroke imaging. The ability of single spin echo T(2) to detect misery perfusion in the rat brain at 1.5 T owing to its sensitivity to blood oxygenation level dependent (BOLD) contrast was studied both theoretically and experimentally. Based on the known physiology of misery perfusion, tissue morphometry and blood relaxation data, T(2) behaviour in misery perfusion was simulated. The interpretation of these computations was experimentally assessed by quantifying T(2) in a rat model for cerebral misery perfusion. CBF was quantified with the H(2) clearance method. A drop of CBF from 58+/-8 to 17+/-3 ml/100 g/min in the parieto-frontal cortex caused shortening of T(2) from 66.9+/-0.4 to 64.6+/-0.5 ms. Under these conditions, no change in diffusion MRI was detected. In contrast, the cortex with CBF of 42+/-7 ml/100 g/min showed no change in T(2). Computer simulations accurately predicted these T(2) responses. The present study shows that the acute drop of CBF by 70% causes a negative BOLD that is readily detectable by T(2) MRI at 1.5 T. Thus BOLD may serve as an index of misery perfusion thus revealing viable tissue with increased OER.

Imaging in cerebrovascular disease

Various functional imaging modalities can be applied in acute ischaemic stroke to identify functionally impaired, but morphologically preserved tissue (i.e. the penumbra), and to distinguish it from irreversibly damaged tissue. Flow thresholds for irreversible tissue destruction resulting in functional impairment, as determined by positron emission tomography, perfusion and diffusion-weighted magnetic resonance imaging, single-photon computed tomography and xenon computed tomography, were comparable and ranged between 5 and 12 ml/100 g per min for the lower and 14 and 22 ml/100 g per min for the upper limit of penumbra. These imaging modalities help to select patients for thrombolytic therapy and provide evidence for the effect of this treatment on critically perfused tissue. They can also serve as surrogate markers in the evaluation of therapeutic efficacy. Further progress in interventional neuroradiology has been achieved with intra-arterial thrombolysis, which has become a treatment option beyond the 3-h therapeutic window in acute ischaemic stroke. Angioplasty and stenting of stenosis of arteries that supply the brain with blood have reached a point in their development at which a randomized trial to compare these treatments with vascular surgery is warranted.

Magnetic resonance prediction of outcome after thrombolytic treatment

Treatment of clinical stroke with recombinant tissue plasminogen activator (rt-PA) carries the risk of hemorrhagic complications. Hence, predictors of therapeutic outcome with respect to (a) reperfusion and (b) tissue recovery would be very useful to identify potentially salvageable brain tissue. Magnetic resonance (MR) parameters, especially the apparent diffusion coefficient of water (ADC), perfusion-weighted imaging (PWI) and T(2) relaxometry are thought to provide this information. We evaluated the prognostic implications of ADC, PWI and T(2) relaxometry immediately before initiation of thrombolytic treatment in a model of clot embolism in rats. Animals (n = 14) were treated with intraarterial rt-PA (10 mg/kg) at 90 min after embolism. MR imaging was repeatedly performed at 4.7 T before and up to 5.5 h after embolism. ADC was calculated from diffusion-weighted images (b-values: 30, 765, 1500 s/mm(2)), arterial spin tagging was used for PWI, and quantitative T(2) relaxometry was performed with a Carr-Purcell-Meiboom-Gill (CPMG) sequence. A reperfusion index was calculated to assess the quality of thrombolytic recanalization. The decline of ADC at the end of the experiment to below 80% of control was defined as unfavorable outcome. The probability of tissue injury at the end of the experiments increased with the severity of ADC changes before the initiation of treatment (probability of unfavorable outcome: 21%, 44%, 65% for ADC values of 80-90%, 70-80% and <70% of control, respectively). Pretreatment PWI or T(2) relaxometry also correlated with outcome but-alone or in combination with pretreatment ADC maps-did not improve injury prediction over that obtained by ADC alone. Outcome was influenced positively by successful reperfusion the quality of which, however, could not be predicted by pre-treatment MR characteristics. The data demonstrate that ADC mapping performed before the initiation of thrombolytic treatment provides reliable risk assessment of impeding brain injury but due to uncertainties of postischemic reperfusion does not allow precise outcome prediction in individual experiments.

Postictal diffusion-weighted imaging for the localization of focal epileptic areas in temporal lobe epilepsy

PURPOSE

Diffusion-weighted MR imaging (DWI) is a novel technique to delineate focal areas of cytotoxic edema of various etiologies. We hypothesized that DWI may also detect the epileptogenic region and adjacent areas during the ictal and early postictal periods in patients with temporal lobe epilepsy (TLE).

METHODS

We studied patients with intractable TLE (n = 9), due to hippocampal sclerosis (HS, n = 7), left mesial temporal lobe tumor (n = 1), and of unknown etiology (n = 1). Informed consent was obtained before inclusion in the study. All patients with single short seizures were scanned immediately after EEG-documented seizures (between 45 and 150 min); one of two patients in status was scanned 14 h after cessation of seizures. DWI results were analyzed visually and by calculating apparent diffusion coefficient (ADC) maps.

RESULTS

We found significant decreases in ADC postictally in one of six patients with TLE due to HS and single short seizures. One patient with an incompletely resected temporal lobe tumor also exhibited ADC abnormalities. One patient in focal status epilepticus revealed a decrease in ADC, and one patient with a continuous aura had no DWI abnormality.

CONCLUSIONS

Postictal DWI technique may occasionally help delineate epileptic areas in some patients with TLE. Yield is low in patients with HS and single short seizures: it may be higher in patients with tumor or status epilepticus.

Multispectral analysis of the temporal evolution of cerebral ischemia in the rat brain

A major difficulty in staging and predicting ischemic brain injury by magnetic resonance (MR) imaging is the time-varying nature of the MR parameters within the ischemic lesion. A new multispectral (MS) approach is described to characterize cerebral ischemia in a time-independent fashion. MS analysis of five MR parameters (mean diffusivity, diffusion anisotropy, T2, proton density, and perfusion) was employed to characterize the progression of ischemic lesion in the rat brain following 60 minutes of transient focal ischemia. k-Means (KM) and fuzzy c-means (FCM) classification methods were employed to define the acute and subacute ischemic lesion. KM produced an estimate of lesion volume that was highly correlated with postmortem infarct volume, independent of the age of the lesion. Overall classification rates for KM exceeded FCM at acute and subacute time points as follows: KM, 90.5%, 94.4%, and 95. 9%; FCM, 82.4%, 90.6%, and 82.6% (for 45 minutes, 180 minutes, and 24-120 hours post MCAO groups). MS analysis also offers a formal method of combining diffusion and perfusion parameters to provide an estimate of the ischemic penumbra (KM classification rate = 70.3%). J. Magn. Reson. Imaging 2000;12:842-858.

The role of magnetic resonance imaging and spectroscopy in transplantation: from animal models to man

Critical success factors in solid organ and vascular transplantation are the assessment of graft status/viability as well as stringent monitoring of transplant recipients, preferentially using noninvasive techniques. This review addresses the application of magnetic resonance imaging (MRI) and spectroscopy (MRS) in the field of transplantation. The first section is devoted to the description of the main MR techniques used for monitoring the status of the graft noninvasively. Subsequently, the role of MRI/MRS in the analysis of the viability of organs for transplantation is discussed. Since chronic rejection remains a major difficulty, development of new therapies is still ongoing. Thus, the third part is devoted to the use of MRI/MRS for monitoring graft rejection in animal models of transplantation. This is followed by a discussion of clinical studies of transplantation involving MRI/MRS. Finally, a general appraisal is made on available imaging techniques for the non-invasive characterization of grafts in situ, highlighting the role of MR methods in the field of transplantation.

Early detection of irreversible cerebral ischemia in the rat using dispersion of the magnetic resonance imaging relaxation time, T1rho

The impact of brain imaging on the assessment of tissue status is likely to increase with the advent of treatment methods for acute cerebral ischemia. Multimodal magnetic resonance imaging (MRI) demonstrates potential for selecting stroke therapy patients by identifying the presence of acute ischemia, delineating the perfusion defect, and excluding hemorrhage. Yet, the identification of tissue subject to reversible or irreversible ischemia has proven to be difficult. Here, the authors show that T1 relaxation time in the rotating frame, so-called T1rho, serves as a sensitive MRI indicator of cerebral ischemia in the rat. The T1rho prolongs within minutes after a drop in the CBF of less than 22 mL 100 g(-1) min(-1). Dependence of T1rho on spin-lock amplitude, termed as T1rho dispersion, increases by approximately 20% on middle cerebral artery (MCA) occlusion, comparable with the magnitude of diffusion reduction. The T1rho dispersion change dynamically increases to be 38% +/- 10% by the first 60 minutes of ischemia in the brain region destined to develop infarction. Following reperfusion after 45 minutes of MCA occlusion, the tissue with elevated T1rho dispersion (yet normal diffusion) develops severe histologically verified neuronal damage; thus, the former parameter unveils an irreversible condition earlier than currently available MRI methods. The T1rho dispersion as a novel MRI index of cerebral ischemia may be useful in determination of the therapeutic window for acute ischemic stroke.

Magnetic resonance assessment of acute and chronic stroke

This article describes the important role of magnetic resonance imaging (MRI) in noninvasively assessing human focal ischemic stroke. Conventional MRI, diffusion-weighted and/or perfusion-weighted imaging have been used to facilitate both the qualitative and quantitative evaluation of heterogeneity of ischemic brain tissue. Further, by combining 2 or more magnetic resonance parameters, tissue-signature models have been developed that may be used as surrogate markers of tissue histopathology to characterize ischemic tissue as salvageable, necrotic, or tissue in transition to necrosis. Magnetic resonance tissue-signature models and results are presented. Dynamic changes in the evolution of ischemic tissue to infarction are also discussed. Recovery from acute stroke was studied with blood oxygenation level-dependent functional MRI to investigate the neural mechanisms for recovery from aphasia after stroke.

Ischemic penumbra: evidence from functional imaging in man

The ischemic penumbra is defined as tissue with flow within the thresholds for maintenance of function and of morphologic integrity. Penumbra tissue has the potential for recovery and therefore is the target for interventional therapy in acute ischemic stroke. The identification of the penumbra necessitates measuring flow reduced less than the functional threshold and differentiating between morphologic integrity and damage. This can be achieved by multitracer positron emission tomography (PET) and perfusion-weighted (PW) and diffusion-weighted magnetic resonance imaging (DW-MRI) in experimental models, in which the recovery of critically perfused tissue or its conversion to infarction was documented in repeat studies. Neuroimaging modalities applied in patients with acute ischemic stroke--multitracer PET, PW- and DW-MRI, single photon emission computed tomography (SPECT), perfusion, and Xe-enhanced computed tomography (CT)-- often cannot reliably identify penumbra tissue: multitracer studies for the assessment of flow and irreversible metabolic damage usually cannot be performed in the clinical setting; CT and MRI do not reliably detect irreversible damage in the first hours after stroke, and even DW-MRI may be misleading in some cases: determinations of perfusion alone yield a poor estimate of the state of the tissue as long as the time course of changes is not known in individual cases. Therefore, the range of flow values in ischemic tissue found later, either within or outside the infarct, was rather broad. New tracers--for example, receptor ligands or hypoxia markers--might improve the identification of penumbra tissue in the future. Despite these methodologic limitations, the validity of the concept of the penumbra was proven in several therapeutic studies in which thrombolytic treatment reversed critical ischemia and decreased the volume of final infarcts. Such neuroimaging findings might serve as surrogate targets in the selection of other therapeutic strategies for large clinical trials.