Low‐Field MRI of Stroke: Challenges and Opportunities

Spatiotemporal encoding MRI in a portable low-field system

PURPOSE

Demonstrate the potential of spatiotemporal encoding (SPEN) MRI to deliver largely undistorted 2D, 3D, and diffusion weighted images on a 110 mT portable system.

METHODS

SPEN's quadratic phase modulation was used to subsample the low-bandwidth dimension of echo planar acquisitions, delivering alias-free images with an enhanced immunity to image distortions in a laboratory-built, low-field, portable MRI system lacking multiple receivers.

RESULTS

Healthy brain images with different SPEN time-bandwidth products and subsampling factors were collected. These compared favorably to EPI acquisitions including topup corrections. Robust 3D and diffusion weighted SPEN images of diagnostic value were demonstrated, with 2.5 mm isotropic resolutions achieved in 3 min scans. This performance took advantage of the low specific absorption rate and relative long TEs associated with low-field MRI.

CONCLUSION

SPEN MRI provides a robust and advantageous fast acquisition approach to obtain faithful 3D images and DWI data in low-cost, portable, low-field systems without parallel acceleration.

Low-field MRI for use in neurological diseases

PURPOSE OF REVIEW

To review recent clinical uses of low-field magnetic resonance imaging (MRI) to guide incorporation into neurological practice.

RECENT FINDINGS

Use of low-field MRI has been demonstrated in applications including tumours, vascular pathologies, multiple sclerosis, brain injury, and paediatrics. Safety, workflow, and image quality have also been evaluated.

SUMMARY

Low-field MRI has the potential to increase access to critical brain imaging for patients who otherwise may not obtain imaging in a timely manner. This includes areas such as the intensive care unit and emergency room, where patients could be imaged at the point of care rather than be transported to the MRI scanner. Such systems are often more affordable than conventional systems, allowing them to be more easily deployed in resource constrained settings. A variety of systems are available on the market or in a research setting and are currently being used to determine clinical uses for these devices. The utility of such devices must be fully evaluated in clinical scenarios before adoption into standard practice can be achieved. This review summarizes recent clinical uses of low-field MR as well as safety, workflows, and image quality to aid practitioners in assessing this new technology.

Bringing MRI to low- and middle-income countries: Directions, challenges and potential solutions

The global disparity of magnetic resonance imaging (MRI) is a major challenge, with many low- and middle-income countries (LMICs) experiencing limited access to MRI. The reasons for limited access are technological, economic and social. With the advancement of MRI technology, we explore why these challenges still prevail, highlighting the importance of MRI as the epidemiology of disease changes in LMICs. In this paper, we establish a framework to develop MRI with these challenges in mind and discuss the different aspects of MRI development, including maximising image quality using cost-effective components, integrating local technology and infrastructure and implementing sustainable practices. We also highlight the current solutions-including teleradiology, artificial intelligence and doctor and patient education strategies-and how these might be further improved to achieve greater access to MRI.

Low-Field, Low-Cost, Point-of-Care Magnetic Resonance Imaging

Low-field magnetic resonance imaging (MRI) has recently experienced a renaissance that is largely attributable to the numerous technological advancements made in MRI, including optimized pulse sequences, parallel receive and compressed sensing, improved calibrations and reconstruction algorithms, and the adoption of machine learning for image postprocessing. This new attention on low-field MRI originates from a lack of accessibility to traditional MRI and the need for affordable imaging. Low-field MRI provides a viable option due to its lack of reliance on radio-frequency shielding rooms, expensive liquid helium, and cryogen quench pipes. Moreover, its relatively small size and weight allow for easy and affordable installation in most settings. Rather than replacing conventional MRI, low-field MRI will provide new opportunities for imaging both in developing and developed countries. This article discusses the history of low-field MRI, low-field MRI hardware and software, current devices on the market, advantages and disadvantages, and low-field MRI's global potential.

Quantitative evaluation of CTP derived time-density alterations versus CTP for collateral status prediction with stroke

BACKGROUND AND OBJECTIVES

Collateral status is a pivotal determinant of clinical outcomes in acute ischemic stroke (AIS); however, its evaluation can be challenging. We investigated the predictive value of CT perfusion (CTP) derived time and density alterations versus CTP for collateral status prediction in AIS.

METHODS

Consecutive patients with anterior circulation occlusion within 24 h were retrospectively included. Time-density curves of the CTP specified ischemic core, penumbra, and the corresponding contralateral unaffected brain were obtained. The collateral status was dichotomised into robust (4-5 scores) and poor (0-3 scores) using multiphase collateral scoring, as described by Menon et al.. Receiver operating characteristic curves and multivariable regression analysis were performed to assess the predictive ability of CTP-designated tissue time and density alterations, CTP for robust collaterals, and favourable outcomes (mRS score of 0-2 at 90 days).

RESULTS

One-hundred patients (median age, 68 years; interquartile range, 57-80 years; 61 men) were included. A smaller ischemic core, shorter peak time delay, lower peak density decrease, lower cerebral blood volume ratio, and cerebral blood flow ratio in the CTP specified ischemic core were significantly associated with robust collaterals (PFDR ≤ 0.004). The peak time delay demonstrated the highest diagnostic value (AUC, 0.74; P < 0.001) with 66.7 % sensitivity and 73.7 % specificity. Furthermore, the peak time delay of less than 8.5 s was an independent predictor of robust collaterals and favourable clinical outcomes.

CONCLUSIONS

Robust collateral status was significantly associated with the peak time delay in the ischemic core. It is a promising image marker for predicting collateral status and functional outcomes in AIS.

Repeatability of image quality in very low-field MRI

BACKGROUND

Very low-field MR has emerged as a promising complementary device to high-field MRI scanners, offering several advantages. One of the key benefits is that very low-field scanners are generally more portable and affordable to purchase and maintain, making them an attractive option for medical facilities looking to reduce costs. Very low-field MRI systems also have lower RF power deposition, making them safer and less likely to cause tissue heating or other safety concerns. They are also simpler to maintain, as they do not require cooling agents such as liquid helium. However, these portable MR scanners are impacted by temperature, lower magnetic field strength, and inhomogeneity, resulting in images with lower signal-to-noise ratio (SNR) and higher geometric distortions. It is essential to investigate and tabulate the variations in these parameters to establish bounds so that subsequent in vivo studies and deployment of these portable systems can be well informed.

PURPOSE

The aim of this work is to investigate the repeatability of image quality metrics such as SNR and geometrical distortion at 0.05 T over 10 days and three sessions per day.

METHODS

We acquired repeatability data over 10 days with three sessions per day. The measurements included temperature, humidity, transmit frequency, off-resonance maps, and 3D turbo spin echo (TSE) images of an in vitro phantom. This resulted in a protocol with 11 sequences. We also acquired a 3 T data set for reference. The image quality metrics included computing SNR and eccentricity (to assess geometrical distortion) to investigate the repeatability of 0.05 T image quality. The image reconstruction included drift correction, k-space filtering, and off-resonance correction. We computed the experimental parameters' coefficient of variation (CV) and the resulting image quality metrics to assess repeatability. We have explored the impact of electromagnetic interference (EMI) on image quality in very low-field MRI. The investigation involved varying both the distance and amplitude of the EMI-producing coil from the signal generator to analyze their effects on image quality.

RESULTS

The range of temperature measured during the study was within 1.5 °C. The off-resonance maps acquired before and after the 3D TSE showed similar hotspots and were changed mainly by a global constant. The SNR measurements were highly repeatable across sessions and over the 10 days, quantified by a CV of 6.7%. The magnetic field inhomogeneity effects quantified by eccentricity showed a CV of 13.7%, but less than 5.1% in two of the three sessions over 10 days. The use of conjugate phase reconstruction mitigated geometrical distortion artifacts. Temperature and humidity did not significantly affect SNR or mean frequency drift within the ranges of these environmental factors investigated. The EMI experiment showed that as the amplitude increased the SNR decreased, and concurrently the root mean square of the background increased with a rise in EMI amplitude or a reduction in distance.

CONCLUSIONS

We found that humidity and temperature in the range investigated did not impact SNR or frequency. Based on the CV values computed session-wise and for the overall study, our findings indicate high repeatability for SNR and magnetic field homogeneity.

Detection of Intracerebral Hemorrhage Using Low-Field, Portable Magnetic Resonance Imaging in Patients With Stroke

BACKGROUND

Neuroimaging is essential for detecting spontaneous, nontraumatic intracerebral hemorrhage (ICH). Recent data suggest ICH can be characterized using low-field magnetic resonance imaging (MRI). Our primary objective was to investigate the sensitivity and specificity of ICH on a 0.064T portable MRI (pMRI) scanner using a methodology that provided clinical information to inform rater interpretations. As a secondary aim, we investigated whether the incorporation of a deep learning (DL) reconstruction algorithm affected ICH detection.

METHODS

The pMRI device was deployed at Yale New Haven Hospital to examine patients presenting with stroke symptoms from October 26, 2020 to February 21, 2022. Three raters independently evaluated pMRI examinations. Raters were provided the images alongside the patient's clinical information to simulate real-world context of use. Ground truth was the closest conventional computed tomography or 1.5/3T MRI. Sensitivity and specificity results were grouped by DL and non-DL software to investigate the effects of software advances.

RESULTS

A total of 189 exams (38 ICH, 89 acute ischemic stroke, 8 subarachnoid hemorrhage, 3 primary intraventricular hemorrhage, 51 no intracranial abnormality) were evaluated. Exams were correctly classified as positive or negative for ICH in 185 of 189 cases (97.9% overall accuracy). ICH was correctly detected in 35 of 38 cases (92.1% sensitivity). Ischemic stroke and no intracranial abnormality cases were correctly identified as blood-negative in 139 of 140 cases (99.3% specificity). Non-DL scans had a sensitivity and specificity for ICH of 77.8% and 97.1%, respectively. DL scans had a sensitivity and specificity for ICH of 96.6% and 99.3%, respectively.

CONCLUSIONS

These results demonstrate improvements in ICH detection accuracy on pMRI that may be attributed to the integration of clinical information in rater review and the incorporation of a DL-based algorithm. The use of pMRI holds promise in providing diagnostic neuroimaging for patients with ICH.

Low-field MRI: A report on the 2022 ISMRM workshop

In March 2022, the first ISMRM Workshop on Low-Field MRI was held virtually. The goals of this workshop were to discuss recent low field MRI technology including hardware and software developments, novel methodology, new contrast mechanisms, as well as the clinical translation and dissemination of these systems. The virtual Workshop was attended by 368 registrants from 24 countries, and included 34 invited talks, 100 abstract presentations, 2 panel discussions, and 2 live scanner demonstrations. Here, we report on the scientific content of the Workshop and identify the key themes that emerged. The subject matter of the Workshop reflected the ongoing developments of low-field MRI as an accessible imaging modality that may expand the usage of MRI through cost reduction, portability, and ease of installation. Many talks in this Workshop addressed the use of computational power, efficient acquisitions, and contemporary hardware to overcome the SNR limitations associated with low field strength. Participants discussed the selection of appropriate clinical applications that leverage the unique capabilities of low-field MRI within traditional radiology practices, other point-of-care settings, and the broader community. The notion of "image quality" versus "information content" was also discussed, as images from low-field portable systems that are purpose-built for clinical decision-making may not replicate the current standard of clinical imaging. Speakers also described technical challenges and infrastructure challenges related to portability and widespread dissemination, and speculated about future directions for the field to improve the technology and establish clinical value.

Current role of portable MRI in diagnosis of acute neurological conditions

Neuroimaging is an inevitable component of the assessment of neurological emergencies. Magnetic resonance imaging (MRI) is the preferred imaging modality for detecting neurological pathologies and provides higher sensitivity than other modalities. However, difficulties such as intra-hospital transport, long exam times, and availability in strict access-controlled suites limit its utility in emergency departments and intensive care units (ICUs). The evolution of novel imaging technologies over the past decades has led to the development of portable MRI (pMRI) machines that can be deployed at point-of-care. This article reviews pMRI technologies and their clinical implications in acute neurological conditions. Benefits of pMRI include timely and accurate detection of major acute neurological pathologies such as stroke and intracranial hemorrhage. Additionally, pMRI can be potentially used to monitor the progression of neurological complications by facilitating serial measurements at the bedside.

CNN-Res: deep learning framework for segmentation of acute ischemic stroke lesions on multimodal MRI images

BACKGROUND

Accurate segmentation of stroke lesions on MRI images is very important for neurologists in the planning of post-stroke care. Segmentation helps clinicians to better diagnose and evaluation of any treatment risks. However, manual segmentation of brain lesions relies on the experience of neurologists and is also a very tedious and time-consuming process. So, in this study, we proposed a novel deep convolutional neural network (CNN-Res) that automatically performs the segmentation of ischemic stroke lesions from multimodal MRIs.

METHODS

CNN-Res used a U-shaped structure, so the network has encryption and decryption paths. The residual units are embedded in the encoder path. In this model, to reduce gradient descent, the residual units were used, and to extract more complex information in images, multimodal MRI data were applied. In the link between the encryption and decryption subnets, the bottleneck strategy was used, which reduced the number of parameters and training time compared to similar research.

RESULTS

CNN-Res was evaluated on two distinct datasets. First, it was examined on a dataset collected from the Neuroscience Center of Tabriz University of Medical Sciences, where the average Dice coefficient was equal to 85.43%. Then, to compare the efficiency and performance of the model with other similar works, CNN-Res was evaluated on the popular SPES 2015 competition dataset where the average Dice coefficient was 79.23%.

CONCLUSION

This study presented a new and accurate method for the segmentation of MRI medical images using a deep convolutional neural network called CNN-Res, which directly predicts segment maps from raw input pixels.

Brain imaging with portable low-field MRI

The advent of portable, low-field MRI (LF-MRI) heralds new opportunities in neuroimaging. Low power requirements and transportability have enabled scanning outside the controlled environment of a conventional MRI suite, enhancing access to neuroimaging for indications that are not well suited to existing technologies. Maximizing the information extracted from the reduced signal-to-noise ratio of LF-MRI is crucial to developing clinically useful diagnostic images. Progress in electromagnetic noise cancellation and machine learning reconstruction algorithms from sparse k-space data as well as new approaches to image enhancement have now enabled these advancements. Coupling technological innovation with bedside imaging creates new prospects in visualizing the healthy brain and detecting acute and chronic pathological changes. Ongoing development of hardware, improvements in pulse sequences and image reconstruction, and validation of clinical utility will continue to accelerate this field. As further innovation occurs, portable LF-MRI will facilitate the democratization of MRI and create new applications not previously feasible with conventional systems.

Iron oxide nanoparticles as positive T1 contrast agents for low-field magnetic resonance imaging at 64 mT

We have investigated the efficacy of superparamagnetic iron oxide nanoparticles (SPIONs) as positive T₁ contrast agents for low-field magnetic resonance imaging (MRI) at 64 millitesla (mT). Iron oxide-based agents, such as the FDA-approved ferumoxytol, were measured using a variety of techniques to evaluate T₁ contrast at 64 mT. Additionally, we characterized monodispersed carboxylic acid-coated SPIONs with a range of diameters (4.9-15.7 nm) in order to understand size-dependent properties of T₁ contrast at low-field. MRI contrast properties were measured using 64 mT MRI, magnetometry, and nuclear magnetic resonance dispersion (NMRD). We also measured MRI contrast at 3 T to provide comparison to a standard clinical field strength. SPIONs have the capacity to perform well as T₁ contrast agents at 64 mT, with measured longitudinal relaxivity (r₁) values of up to 67 L mmol^-1 s^-1, more than an order of magnitude higher than corresponding r₁ values at 3 T. The particles exhibit size-dependent longitudinal relaxivities and outperform a commercial Gd-based agent (gadobenate dimeglumine) by more than eight-fold at physiological temperatures. Additionally, we characterize the ratio of transverse to longitudinal relaxivity, r₂/r₁ and find that it is ~ 1 for the SPION based agents at 64 mT, indicating a favorable balance of relaxivities for T₁-weighted contrast imaging. We also correlate the magnetic and structural properties of the particles with models of nanoparticle relaxivity to understand generation of T₁ contrast. These experiments show that SPIONs, at low fields being targeted for point-of-care low-field MRI systems, have a unique combination of magnetic and structural properties that produce large T₁ relaxivities.

Enhanced 129 Xe T1 relaxation in whole blood and in the presence of SPIONs at low magnetic field strengths

PURPOSE

To compare the effect of superparamagnetic iron oxide nanoparticles (SPIONs) on the T1 of 129 Xe and 1 H and to measure the relaxation of 129 Xe in blood at low and high magnetic field strengths.

METHODS

129 Xe and 1 H T1 relaxometry was performed at low- and high-field strengths in samples containing different SPION concentrations, while imaging was used to compare the contrast obtainable in these two field regimes. In vivo experiments at variable field strengths were performed to determine the depolarization of 129 Xe in blood and the feasibility of in vivo dissolved-phase spectroscopy and imaging at low field.

RESULTS

The SPION relaxivity was substantially greater at low field for 1 H, increasing from 0.92 ± 0.06 mM s-1 at 11.7T to 31.5 ± 1.8 mM s-1 at 0.6 mT, and for 129 Xe, which increased from 0.13 ± 0.03 mM s-1 at 11.7T to 7.32 ± 0.71 mM s-1 at 2.1 mT. The additional MR signal loss increased from 0.7% at 9.4T to 20.6 ± 4.2% at 0.6 mT for 1 H and from -0.7 ± 3.4% at 9.4T to 12.7 ± 3.5% at 2.1 mT for 129 Xe. Blood was found to depolarize 129 Xe below 3T in a manner inversely proportional to the field strength. In vitro studies at 2.1 mT suggest 129 Xe relaxation times below 5 s in blood dilutions as low as 0.4% volume.

CONCLUSION

SPIONs longitudinal relaxivity increases at low field both for 1 H and 129 Xe. The depolarization of xenon in blood, which is found to increase below 3T, effectively prevents in vivo dissolved-phase spectroscopy and imaging at low-field strengths.

Concomitant field compensation of spiral turbo spin-echo at 0.55 T

OBJECTIVE

Diagnostic-quality neuroimaging methods are vital for widespread clinical adoption of low field MRI. Spiral imaging is an efficient acquisition method that can mitigate the reduced signal-to-noise ratio at lower field strengths. As concomitant field artifacts are worse at lower field, we propose a generalizable quadratic gradient-field nulling as an echo-to-echo compensation and apply it to spiral TSE at 0.55 T.

MATERIALS AND METHODS

A spiral in-out TSE acquisition was developed with a compensation for concomitant field variation between spiral interleaves, by adding bipolar gradients around each readout to minimize phase differences at each refocusing pulse. Simulations were performed to characterize concomitant field compensation approaches. We demonstrate our proposed compensation method in phantoms and (n = 8) healthy volunteers at 0.55 T.

RESULTS

Spiral read-outs with integrated spoiling demonstrated strong concomitant field artifacts but were mitigated using the echo-to-echo compensation. Simulations predicted a decrease of concomitant field phase RMSE between echoes of 42% using the proposed compensation. Spiral TSE improved SNR by 17.2 ± 2.3% compared to reference Cartesian acquisition.

DISCUSSION

We demonstrated a generalizable approach to mitigate concomitant field artifacts for spiral TSE acquisitions via the addition of quadratic-nulling gradients, which can potentially improve neuroimaging at low-field through increased acquisition efficiency.

Is improved access to magnetic resonance imaging imperative for optimal ischemic stroke care?

Neuroimaging, including CT and MRI, is integral to ischemic stroke (IS) treatment, management, and prevention. However, the use of MRI for IS patients is limited despite its potential to provide high-quality images that yield definitive information related to the management of IS. MRI is beneficial when the information provided by CT is insufficient for decisions related to the diagnosis, etiology, or treatment of IS. In the emergency setting, MRI can improve the diagnostic accuracy of CT-negative acute ischemic strokes (AIS) and ensure a better selection of patients for reperfusion therapies with thrombolysis and/or thrombectomy. Moreover, MR imaging may help avoid hospital admissions for patients with stroke mimics, facilitate earlier discharge, and reduce overall hospital costs. MRI in the in-patient setting can help determine stroke etiology to aid in stroke prevention management upon discharge. Furthermore, early access to MRI in IS out-patients can aid in diagnosing, risk stratifying, and determining optimal management strategies for patients with a TIA or a minor stroke. Recent technological advances, particularly low-to-mid-field MR scanners, can improve access to MRI. These MR scanners provide faster protocols, cost-effectiveness, smaller footprints, safety, and lower power requirements. In conclusion, MRI use for IS treatment, management, and prevention is imperative and justifiable, and the latest technological advancements in MR scanners hold the potential to enhance access.

A framework for advancing sustainable magnetic resonance imaging access in Africa

Magnetic resonance imaging (MRI) technology has profoundly transformed current healthcare systems globally, owing to advances in hardware and software research innovations. Despite these advances, MRI remains largely inaccessible to clinicians, patients, and researchers in low-resource areas, such as Africa. The rapidly growing burden of noncommunicable diseases in Africa underscores the importance of improving access to MRI equipment as well as training and research opportunities on the continent. The Consortium for Advancement of MRI Education and Research in Africa (CAMERA) is a network of African biomedical imaging experts and global partners, implementing novel strategies to advance MRI access and research in Africa. Upon its inception in 2019, CAMERA sets out to identify challenges to MRI usage and provide a framework for addressing MRI needs in the region. To this end, CAMERA conducted a needs assessment survey (NAS) and a series of symposia at international MRI society meetings over a 2-year period. The 68-question NAS was distributed to MRI users in Africa and was completed by 157 clinicians and scientists from across Sub-Saharan Africa (SSA). On average, the number of MRI scanners per million people remained at less than one, of which 39% were obsolete low-field systems but still in use to meet daily clinical needs. The feasibility of coupling stable energy supplies from various sources has contributed to the growing number of higher-field (1.5 T) MRI scanners in the region. However, these systems are underutilized, with only 8% of facilities reporting clinical scans of 15 or more patients per day, per scanner. The most frequently reported MRI scans were neurological and musculoskeletal. The CAMERA NAS combined with the World Health Organization and International Atomic Energy Agency data provides the most up-to-date data on MRI density in Africa and offers a unique insight into Africa's MRI needs. Reported gaps in training, maintenance, and research capacity indicate ongoing challenges in providing sustainable high-value MRI access in SSA. Findings from the NAS and focused discussions at international MRI society meetings provided the basis for the framework presented here for advancing MRI capacity in SSA. While these findings pertain to SSA, the framework provides a model for advancing imaging needs in other low-resource settings.

Benchmarking the performance of a low-cost magnetic resonance control system at multiple sites in the open MaRCoS community

PURPOSE

To describe the current properties and capabilities of an open-source hardware and software package that is being developed by many sites internationally with the aim of providing an inexpensive yet flexible platform for low-cost MRI.

METHODS

This article describes three different setups from 50 to 360 mT in different settings, all of which used the MaRCoS console for acquiring data, and different types of software interface (custom-built GUI or Pulseq overlay) to acquire it.

RESULTS

Images are presented both from phantoms and in vivo from healthy volunteers to demonstrate the image quality that can be obtained from the MaRCoS hardware/software interfaced to different low-field magnets.

CONCLUSIONS

The results presented here show that a number of different sequences commonly used in the clinic can be programmed into an open-source system relatively quickly and easily, and can produce good quality images even at this early stage of development. Both the hardware and software will continue to develop, and it is an aim of this article to encourage other groups to join this international consortium.

Low-field MRI: Clinical promise and challenges

Modern MRI scanners have trended toward higher field strengths to maximize signal and resolution while minimizing scan time. However, high-field devices remain expensive to install and operate, making them scarce outside of high-income countries and major population centers. Low-field strength scanners have drawn renewed academic, industry, and philanthropic interest due to advantages that could dramatically increase imaging access, including lower cost and portability. Nevertheless, low-field MRI still faces inherent limitations in image quality that come with decreased signal. In this article, we review advantages and disadvantages of low-field MRI scanners, describe hardware and software innovations that accentuate advantages and mitigate disadvantages, and consider clinical applications for a new generation of low-field devices. In our review, we explore how these devices are being or could be used for high acuity brain imaging, outpatient neuroimaging, MRI-guided procedures, pediatric imaging, and musculoskeletal imaging. Challenges for their successful clinical translation include selecting and validating appropriate use cases, integrating with standards of care in high resource settings, expanding options with actionable information in low resource settings, and facilitating health care providers and clinical practice in new ways. By embracing both the promise and challenges of low-field MRI, clinicians and researchers have an opportunity to transform medical care for patients around the world. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 6.

Impact of Proprioceptive Neuromuscular Facilitation Technique for Early Rehabilitation to Restore Motor Impairments in a Classic Case of Left Middle Cerebral Artery Stroke

An abrupt hemorrhage or ischemia causes acute onset of stroke. The characteristic feature of hemiplegia is the loss of voluntary movement with the alteration of muscle tone, reflexes, and sensation. In this case, we present a 56-year-old man who suffered from right hemiplegia, facial palsy, and expressive aphasia. The MRI of the brain revealed a hemorrhagic transformation of acute infarct in the left frontoparietal-temporo-occipital lobe. The patient was managed immediately by medical interventions. The physiotherapy treatment was initiated after the stabilization of acute symptoms at an early stage. This case report details the management of the patient with physical therapy and highlights the advantages of exercise therapy, particularly the proprioceptive neuromuscular facilitation technique for enhancing the patient's condition by incorporating physiotherapy protocol from an early stage.

Susceptibility-weighted imaging at high-performance 0.5T magnetic resonance imaging system: Protocol considerations and experimental results

The high-performance low-field magnetic resonance imaging (MRI) system, equipped with modern hardware and contemporary imaging capabilities, has garnered interest within the MRI community in recent years. It has also been proven to have unique advantages over high-field MRI in both physical and cost aspects. However, for susceptibility weighted imaging (SWI), the low signal-to-noise ratio and the long echo time inherent at low field hinder the SWI from being applied to clinical applications. This work optimized the imaging protocol to select suitable parameters such as the values of time of echo (TE), repetition time (TR), and the flip angle (FA) of the RF pulse according to the signal simulations for low-field SWI. To improve the signal-to-noise ratio (SNR) performance, averaging multi-echo magnitude images and BM4D phase denoising were proposed. A comparison of the SWI in 0.5T and 1.5T was carried out, demonstrating the capability to identify magnetic susceptibility differences between variable tissues, especially, the blood veins. This would open the possibility to extend SWI applications in the high-performance low field MRI.

Neuroimaging in Pediatric Stroke

Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.

Denoising Using Noise2Void for Low-Field Magnetic Resonance Imaging: A Phantom Study

To reduce noise for low-field magnetic resonance imaging (MRI) using Noise2Void (N2V) and to demonstrate the N2V validity. N2V is one of the denoising convolutional neural network methods that allows the training of a model without a noiseless clean image. In this study, a kiwi fruit was scanned using a 0.35 Tesla MRI system, and the image qualities at pre- and postdenoising were evaluated. Structural similarity (SSIM), signal-to-noise ratio (SNR), and contrast ratio (CR) were measured, and visual assessment of noise and sharpness was observed. Both SSIM and SNR were significantly improved using N2V (P < 0.05). CR was unchanged between pre- and postdenoising images. The results of visual assessment for noise revealed higher scores in postdenoising images than that in predenoising images. The sharpness scores of postdenoising images were high when SNR was low. N2V provides effective noise reduction and is a useful denoising technique in low-field MRI.

MRI-guided endovascular intervention: current methods and future potential

INTRODUCTION

Image-guided endovascular interventions, performed using the insertion and navigation of catheters through the vasculature, have been increasing in number over the years, as minimally invasive procedures continue to replace invasive surgical procedures. Such endovascular interventions are almost exclusively performed under x-ray fluoroscopy, which has the best spatial and temporal resolution of all clinical imaging modalities. Magnetic resonance imaging (MRI) offers unique advantages and could be an attractive alternative to conventional x-ray guidance, but also brings with it distinctive challenges.

AREAS COVERED

In this review, the benefits and limitations of MRI-guided endovascular interventions are addressed, systems and devices for guiding such interventions are summarized, and clinical applications are discussed.

EXPERT OPINION

MRI-guided endovascular interventions are still relatively new to the interventional radiology field, since significant technical hurdles remain to justify significant costs and demonstrate safety, design, and robustness. Clinical applications of MRI-guided interventions are promising but their full potential may not be realized until proper tools designed to function in the MRI environment are available. Translational research and further preclinical studies are needed before MRI-guided interventions will be practical in a clinical interventional setting.

Pre-thrombectomy prognostic prediction of large-vessel ischemic stroke using machine learning: A systematic review and meta-analysis

Introduction

Machine learning (ML) methods are being increasingly applied to prognostic prediction for stroke patients with large vessel occlusion (LVO) treated with endovascular thrombectomy. This systematic review aims to summarize ML-based pre-thrombectomy prognostic models for LVO stroke and identify key research gaps.

Methods

Literature searches were performed in Embase, PubMed, Web of Science, and Scopus. Meta-analyses of the area under the receiver operating characteristic curves (AUCs) of ML models were conducted to synthesize model performance.

Results

Sixteen studies describing 19 models were eligible. The predicted outcomes include functional outcome at 90 days, successful reperfusion, and hemorrhagic transformation. Functional outcome was analyzed by 10 conventional ML models (pooled AUC=0.81, 95% confidence interval [CI]: 0.77–0.85, AUC range: 0.68–0.93) and four deep learning (DL) models (pooled AUC=0.75, 95% CI: 0.70–0.81, AUC range: 0.71–0.81). Successful reperfusion was analyzed by three conventional ML models (pooled AUC=0.72, 95% CI: 0.56–0.88, AUC range: 0.55–0.88) and one DL model (AUC=0.65, 95% CI: 0.62–0.68).

Conclusions

Conventional ML and DL models have shown variable performance in predicting post-treatment outcomes of LVO without generally demonstrating superiority compared to existing prognostic scores. Most models were developed using small datasets, lacked solid external validation, and at high risk of potential bias. There is considerable scope to improve study design and model performance. The application of ML and DL methods to improve the prediction of prognosis in LVO stroke, while promising, remains nascent.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021266524, identifier CRD42021266524

Mapping the research trends of astrocytes in stroke: A bibliometric analysis

Background

Stroke, including ischemic stroke and hemorrhagic stroke, possesses complex pathological mechanisms such as neuroinflammation, oxidative stress and blood-brain barrier damage. Astrocyte functions have been reported during injury, neuroprotection and cell crosstalk. It plays a key role in exacerbating stroke injury, promoting neurological repair and enhancing neuroregeneration.

Aim

This holistic bibliometric analysis aimed to provide a general overview of the recent advancement and the hotspots in the field of stroke and astrocyte from 2001 to 2021.

Materials and methods

Publications between 2001 and 2021, related to stroke and astrocyte were retrieved from the Web of Science (WOS) and analyzed in Gephi and VOSviewer.

Results

In total, 3789 documents were extracted from the WOS databases. The publications showed stable growth since 2001. The United States and China were the most prolific countries and University of California San Francisco and Oakland University were the most influential institutes. The top four most productive journals were Brain Research, Journal of Cerebral Blood Flow and Metabolism, Glia and Journal of Neuroinflammation. Keywords frequency and co-occurrence analysis revealed that the topics related to “micro-RNA”, “toll like receptor”, “neuroinflammation”, “autophagy” and “interleukin” were research frontiers. The field of stroke and astrocyte focused on several aspects, such as the role of astrocytes in the treatment of stroke, metabolic changes in astrocytes, the protective role of apoptosis in astrocytes after oxidative stress injury and neurovascular units.

Conclusion

This comprehensive bibliometric study provides an updated perspective on the trend of research associated with stroke and astrocyte. It will benefit scientific community to identify the important issues, future directions and provide a novel understanding of stroke pathophysiology, hotspots and frontiers to facilitate future research direction.

Sheared two-dimensional radiofrequency excitation for off-resonance robustness and fat suppression in reduced field-of-view imaging

PURPOSE

Two-dimensional (2D) echo-planar radiofrequency (RF) pulses are widely used for reduced field-of-view (FOV) imaging in applications such as diffusion-weighted imaging. However, long pulse durations render the 2D RF pulses sensitive to off-resonance effects, causing local signal losses in reduced-FOV images. This work aims to achieve off-resonance robustness for 2D RF pulses via a sheared trajectory design.

THEORY AND METHODS

A sheared 2D RF pulse design is proposed to reduce pulse durations while covering identical excitation k-space extent as a standard 2D RF pulse. For a given shear angle, the number of sheared trajectory lines is minimized to obtain the shortest pulse duration, such that the excitation replicas are repositioned outside the slice stack to guarantee unlimited slice coverage. A target fat/water signal ratio of 5% is chosen to achieve robust fat suppression.

RESULTS

Simulations, imaging experiments on a custom head and neck phantom, and in vivo imaging experiments in the spinal cord at 3 T demonstrate that the sheared 2D RF design provides significant improvement in image quality while preserving profile sharpnesses. In regions with high off-resonance effects, the sheared 2D RF pulse improves the signal by more than 50% when compared to the standard 2D RF pulse.

CONCLUSION

The proposed sheared 2D RF design successfully reduces pulse durations, exhibiting significantly improved through-plane off-resonance robustness, while providing unlimited slice coverage and high fidelity fat suppression. This method will be especially beneficial in regions suffering from a variety of off-resonance effects, such as spinal cord and breast.

Improving local SNR of a single-channel 54.6 mT MRI system using additional LC-resonator

Very-low field magnetic resonance imaging (VLF-MRI, B0 < 0.1T) has an essential application in medical imaging diagnosis because of its light weight and low cost. For single-channel RF coil VLF-MRI system, a planar spiral LC-resonator placed on the surface of samples was designed to improve the local SNR. First, an equivalent circuit model was established to evaluate the boosting effects on radiofrequency (RF) magnetic field and SNR. Second, the relationship between the resonant capacitance and the transmission coefficient was deduced according to the circuit model, and the appropriate resonant capacitance was obtained. Then, the influence of the diameter and the number of turns of the LC-resonator on the SNR is considered, and the structure of the LC-resonator was optimized to maximize the SNR. Finally, a phantom MRI experiment was carried out with our home-built 54.6 mT MRI system to compare the SNR of the experiment with the calculation, the SNR enhancement trend of the two was consistent. Additional experiments were conducted using orange and chicken leg to demonstrate the SNR enhancement abilities of the LC-resonator. The enhancement of SNR reached up to 1.8-fold and 2.2-fold depending on the distance between the sample and LC-resonator. For comparison, we conducted imaging experiments on surface receiving coil with the same parameters, and the results show that the SNR of the LC resonator is comparable to that of the surface coil. The reported LC-resonator provide a low-cost local enhancement method for VLF-MRI.

Potential of Stroke Imaging Using a New Prototype of Low-Field MRI: A Prospective Direct 0.55 T/1.5 T Scanner Comparison

Objectives: Ischemic stroke is a leading cause of mortality and acquired disability worldwide and thus plays an enormous health-economic role. Imaging of choice is computed-tomographic (CT) or magnetic resonance imaging (MRI), especially diffusion-weighted (DW) sequences. However, MR imaging is associated with high costs and therefore has a limited availability leading to low-field-MRI techniques increasingly coming into focus. Thus, the aim of our study was to assess the potential of stroke imaging with low-field MRI. Material and Methods: A scanner comparison was performed including 27 patients (17 stroke cohort, 10 control group). For each patient, a brain scan was performed first with a 1.5T scanner and afterwards with a 0.55T scanner. Scan protocols were as identical as possible and optimized. Data analysis was performed in three steps: All DWI/ADC (apparent diffusion coefficient) and FLAIR (fluid attenuated inversion recovery) sequences underwent Likert rating with respect to image impression, resolution, noise, contrast, and diagnostic quality and were evaluated by two radiologists regarding number and localization of DWI and FLAIR lesions in a blinded fashion. Then segmentation of lesion volumes was performed by two other radiologists on DWI/ADC and FLAIR. Results: DWI/ADC lesions could be diagnosed with the same reliability by the most experienced reader in the 0.55T and 1.5T sequences (specificity 100% and sensitivity 92.9%, respectively). False positive findings did not occur. Detection of number/location of FLAIR lesions was mostly equivalent between 0.55T and 1.5T sequences. No significant difference (p = 0.789−0.104) for FLAIR resolution and contrast was observed regarding Likert scaling. For DWI/ADC noise, the 0.55T sequences were significantly superior (p < 0.026). Otherwise, the 1.5T sequences were significantly superior (p < 0.029). There was no significant difference in infarct volume and volume of infarct demarcation between the 0.55T and 1.5T sequences, when detectable. Conclusions: Low-field MRI stroke imaging at 0.55T may not be inferior to scanners with higher field strengths and thus has great potential as a low-cost alternative in future stroke diagnostics. However, there are limitations in the detection of very small infarcts. Further technical developments with follow-up studies must show whether this problem can be solved.

Bedside detection of intracranial midline shift using portable magnetic resonance imaging

Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.

Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage

Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.

Use of Portable Imaging Modalities in Patients With Neurologic Disorders: A Case-Based Discussion

Imaging technologies have significantly improved over the past few decades and play a critical role in the diagnosis and management of patients with neurologic conditions. With the evolution of these technologies to portable versions, significant implications exist for current neurologic care as well as potential improvements for the future. This article serves to describe portable imaging technologies and their potential impact on the field of neurology highlighted through the case of a patient who presented with symptoms consistent with a stroke.

Characterization of displacement forces and image artifacts in the presence of passive medical implants in low-field (<100 mT) permanent magnet-based MRI systems, and comparisons with clinical MRI systems

PURPOSE

To investigate the displacement forces and image artifacts associated with passive medical implants for recently-developed low-field (<100 mT) MRI systems, and to compare these with values from higher field strengths used for clinical diagnosis.

METHODS

Setups were constructed to measure displacement forces in a permanent magnet-based Halbach array used for in vivo MRI at 50 mT, and results compared with measurements at 7 T. Image artifacts were assessed using turbo (fast) spin echo imaging sequences for four different passive medical implants: a septal occluder, iliac stent, pedicle screw and (ferromagnetic) endoscopic clip. Comparisons were made with artifacts produced at 1.5, 3 and 7 T. Finally, specific absorption rate (SAR) simulations were performed to determine under what operating conditions the limits might be approached at low-field.

RESULTS

Displacement forces at 50 mT on all but the ferromagnetic implant were between 1 and 10 mN. Image artifacts at 50 mT were much less than at clinical field strengths for all passive devices, and with the exception of the ferromagnetic clip. SAR simulations show that very long echo train (>128) turbo spin echo sequences can be run with short inter-pulse times (5-10 ms) within SAR limits.

CONCLUSIONS

This work presents the first evaluation of the effects of passive implants at field strengths less than 100 mT in terms of displacement forces, image artifacts and SAR. The results support previous claims that such systems can be used safely and usefully in challenging enviroments such as the intensive care unit.

Improving the field homogeneity of fixed- and variable-diameter discrete Halbach magnet arrays for MRI via optimization of the angular magnetization distribution

The aim of this work was to maximize the homogeneity of fixed- or variable-diameter Halbach array of discrete magnets by optimizing the angular rotation of individual magnets within each ring of the array. Numerical simulations have been performed for magnet arrays with various length:radius ratios (L/R) using a dipole-approximation model. These simulations used an uninformed random-search algorithm, with the initial state corresponding to the classical Halbach dipole configuration. Two different classes of systems were studied, one with magnet rings of constant radius, and the other in which the radius of the rings was allowed to vary to increase the homogeneity. Simulation results showed that for a fixed-diameter array optimization of the angular orientation of individual magnets increased the homogeneity by ~17% for very short magnets, with the improvement dropping to ~5% for L/R values greater than ~3:1, where the homogeneity was measured over a region-of-interest equal to one-half the diameter of the magnet array. An empirical formula was derived which allows easy estimation of the required magnetization angles for any L/R. For a 23-ring variable diameter magnet with L/R of ~4:1 the optimization procedure produces an increase in homogeneity of ~18%.