Considerations in high-resolution skeletal muscle diffusion tensor imaging using single-shot echo planar imaging with stimulated-echo preparation and sensitivity encoding

A handbook for beginners in skeletal muscle diffusion tensor imaging: physical basis and technical adjustments

Magnetic resonance imaging (MRI) of skeletal muscle is routinely performed using morphological sequences to acquire anatomical information. Recently, there is an increasing interest in applying advanced MRI techniques that provide pathophysiologic information for skeletal muscle evaluation to complement standard morphologic information. Among these advanced techniques, diffusion tensor imaging (DTI) has emerged as a potential tool to explore muscle microstructure. DTI can noninvasively assess the movement of water molecules in well-organized tissues with anisotropic diffusion, such as skeletal muscle. The acquisition of DTI studies for skeletal muscle assessment requires specific technical adjustments. Besides, knowledge of DTI physical basis and skeletal muscle physiopathology facilitates the evaluation of this advanced sequence and both image and parameter interpretation. Parameters derived from DTI provide a quantitative assessment of muscle microstructure with potential to become imaging biomarkers of normal and pathological skeletal muscle. KEY POINTS: • Diffusion tensor imaging (DTI) allows to evaluate the three-dimensional movement of water molecules inside biological tissues. • The skeletal muscle structure makes it suitable for being evaluated with DTI. • Several technical adjustments have to be considered for obtaining robust and reproducible DTI studies for skeletal muscle assessment, minimizing potential artifacts.

Diffusion MRI fiber diameter for muscle denervation assessment

BACKGROUND

To develop and evaluate a diffusion MRI-based apparent muscle fiber diameter (AFD) method in patients with muscle denervation. It was hypothesized that AFD differences between denervated, non-denervated and control muscles would be greater than those from standard diffusion metrics.

METHODS

A spin-echo diffusion acquisition with multi-b-valued diffusion sampling was used. An orientation-invariant dictionary approach utilized a cylinder-based forward model and multi-compartment model for obtaining restricted and free fractions. Simulations were performed to determine precision, bias, and optimize dictionary parameters. In all, 18 exams of patients with muscle denervation and 8 exams of healthy subjects were performed at 3T. Six regions of interests (ROIs) within separate shoulder muscles were selected, yielding three groups consisting 47 control (healthy), 36 non-denervated (patients), and 68 denervated (patients) muscle ROIs. Two-sample t-tests (α=0.05) between groups were performed with Holm-Bonferroni correction. T2- and fat fraction (FF)-mapping were acquired for comparison.

RESULTS

Mean AFD was 89.7±13.6 µm in control, 71.6±15.3 µm in non-denervated, and 60.7±15.9 µm in denervated muscles and were significantly different (P<0.001) in paired comparisons and in 10/12 individual muscle region comparisons. Correlation between AFD and FF (-0.331, P<0.001) was low, but correlation between FA and FF was negligible (0.197, P=0.016). Correlation was low between AFD and T2 (-0.395, P<0.001) and between FA and T2 (0.359, P<0.001).

CONCLUSIONS

Diffusion MRI-based AFD complements T2- and FF-mapping techniques to non-invasively assess muscle denervation.

The muscle twitch profile assessed with motor unit magnetic resonance imaging

Localised signal voids in diffusion-weighted (DW) images of skeletal muscle have been postulated to occur as a result of muscle fibre contraction and relaxation. We investigated the contrast mechanism of these signal voids using a combination of modelling and experimental measurements by employing DW and phase contrast (PC) imaging sequences. The DW signal and PC signal were simulated for each time point of a theoretical muscle twitch. The model incorporated compaction (simulating actively contracting muscle fibres) and translation (simulating passively moving surrounding fibres). The model suggested that the DW signal depended on contraction time and compaction whereas the PC signal depended on contraction time, compaction and translation. In a retrospective study, we tested this model with subgroup analyses on 10 healthy participants. Electrical nerve stimulation was used to generate muscle twitches in lower leg muscles; the resulting force was measured using an MR-compatible force transducer. At current levels causing a visible muscle twitch (~13 mA), the width of the first signal drop in the DW signal (mean ± SD: 103 ± 20 ms) was comparable with the force contraction time (93 ± 34 ms; intraclass correlation coefficient [ICC] = 0.717, P = .010). At current levels activating single motor units (~9 mA), the contraction time determined from the DW signal was 75 ± 13 ms and comparable with the PC contraction time (81 ± 15 ms; ICC = 0.925, P = .001). The maximum positive velocity was 0.55 ± 0.26 cm/s and the displacement was 0.20 ± 0.10 mm. Voxel-wise analysis revealed localised DW changes occurring together with more widespread phase changes. In conclusion, local signal attenuations in DW images following muscle fibre activation are primarily caused by compaction. The PC sequence also detects translating muscle tissue being passively pulled. The magnitude of the changes in DW and PC images depends on the twitch's contractile properties and percentage contraction. DW imaging and PC imaging can therefore measure twitch profiles of skeletal muscle fibres.

Diffusion Tensor Imaging of Skeletal Muscle Contraction Using Oscillating Gradient Spin Echo

Diffusion tensor imaging (DTI) measures water diffusion in skeletal muscle tissue and allows for muscle assessment in a broad range of neuromuscular diseases. However, current DTI measurements, typically performed using pulsed gradient spin echo (PGSE) diffusion encoding, are limited to the assessment of non-contracted musculature, therefore providing limited insight into muscle contraction mechanisms and contraction abnormalities. In this study, we propose the use of an oscillating gradient spin echo (OGSE) diffusion encoding strategy for DTI measurements to mitigate the effect of signal voids in contracted muscle and to obtain reliable diffusivity values. Two OGSE sequences with encoding frequencies of 25 and 50 Hz were tested in the lower leg of five healthy volunteers with relaxed musculature and during active dorsiflexion and plantarflexion, and compared with a conventional PGSE approach. A significant reduction of areas of signal voids using OGSE compared with PGSE was observed in the tibialis anterior for the scans obtained in active dorsiflexion and in the soleus during active plantarflexion. The use of PGSE sequences led to unrealistically elevated axial diffusivity values in the tibialis anterior during dorsiflexion and in the soleus during plantarflexion, while the corresponding values obtained using the OGSE sequences were significantly reduced. Similar findings were seen for radial diffusivity, with significantly higher diffusivity measured in plantarflexion in the soleus muscle using the PGSE sequence. Our preliminary results indicate that DTI with OGSE diffusion encoding is feasible in human musculature and allows to quantitatively assess diffusion properties in actively contracting skeletal muscle. OGSE holds great potential to assess microstructural changes occurring in the skeletal muscle during contraction, and for non-invasive assessment of contraction abnormalities in patients with muscle diseases.

Exploration of New Contrasts, Targets, and MR Imaging and Spectroscopy Techniques for Neuromuscular Disease - A Workshop Report of Working Group 3 of the Biomedicine and Molecular Biosciences COST Action BM1304 MYO-MRI

Neuromuscular diseases are characterized by progressive muscle degeneration and muscle weakness resulting in functional disabilities. While each of these diseases is individually rare, they are common as a group, and a large majority lacks effective treatment with fully market approved drugs. Magnetic resonance imaging and spectroscopy techniques (MRI and MRS) are showing increasing promise as an outcome measure in clinical trials for these diseases. In 2013, the European Union funded the COST (co-operation in science and technology) action BM1304 called MYO-MRI (www.myo-mri.eu), with the overall aim to advance novel MRI and MRS techniques for both diagnosis and quantitative monitoring of neuromuscular diseases through sharing of expertise and data, joint development of protocols, opportunities for young researchers and creation of an online atlas of muscle MRI and MRS. In this report, the topics that were discussed in the framework of working group 3, which had the objective to: Explore new contrasts, new targets and new imaging techniques for NMD are described. The report is written by the scientists who attended the meetings and presented their data. An overview is given on the different contrasts that MRI can generate and their application, clinical needs and desired readouts, and emerging methods.

Paraspinal Muscle DTI Metrics Predict Muscle Strength

Background

The paraspinal muscles play an important role in the onset and progression of lower back pain. It would be of clinical interest to identify imaging biomarkers of the paraspinal musculature that are related to muscle function and strength. Diffusion tensor imaging (DTI) enables the microstructural examination of muscle tissue and its pathological changes.

Purpose

To investigate associations of DTI parameters of the lumbar paraspinal muscles with isometric strength measurements in healthy volunteers.

Study Type

Prospective.

Subjects

Twenty‐one healthy subjects (12 male, 9 female; age = 30.1 ± 5.6 years; body mass index [BMI] = 27.5 ± 2.6 kg/m²) were recruited.

Field Strength/Sequence

3 T/single‐shot echo planar imaging (ss‐EPI) DTI in 24 directions; six‐echo 3D spoiled gradient echo sequence for chemical shift encoding‐based water–fat separation.

Assessment

Paraspinal muscles at the lumbar spine were examined. Erector spinae muscles were segmented bilaterally; cross‐sectional area (CSA), proton density fat fraction (PDFF), and DTI parameters were calculated. Muscle flexion and extension maximum isometric torque values [Nm] at the back were measured with an isokinetic dynamometer and the ratio of extension to flexion strength (E/F) calculated.

Statistical Tests

Pearson correlation coefficients; multivariate regression models.

Results

Significant positive correlations were found between the ratio of extension to flexion (E/F) strength and mean diffusivity (MD) (P = 0.019), RD (P = 0.02) and the eigenvalues (λ1: P = 0.026, λ2: P = 0.033, λ3: P = 0.014). In multivariate regression models λ3 of the erector spinae muscle λ3 and gender remained statistically significant predictors of E/F (R²_adj = 0.42, P = 0.003).

Data Conclusion

DTI allowed the identification of muscle microstructure differences related to back muscle function that were not reflected by CSA and PDFF. DTI may potentially track subtle changes of back muscle tissue composition.

Level of Evidence: 3

Technical Efficacy: Stage 2

J. Magn. Reson. Imaging 2019;50:816–823.

An Efficient Modelling-Simulation-Analysis Workflow to Investigate Stump-Socket Interaction Using Patient-Specific, Three-Dimensional, Continuum-Mechanical, Finite Element Residual Limb Models

The lack of an efficient modelling-simulation-analysis workflow for creating and utilising detailed subject-specific computational models is one of the key reasons why simulation-based approaches for analysing socket-stump interaction have not yet been successfully established. Herein, we propose a novel and efficient modelling-simulation-analysis workflow that uses commercial software for generating a detailed subject-specific, three-dimensional finite element model of an entire residual limb from Diffusion Tensor MRI images in <20 min. Moreover, to complete the modelling-simulation-analysis workflow, the generated subject-specific residual limb model is used within an implicit dynamic FE simulation of bipedal stance to predict the potential sites of deep tissue injury. For this purpose, a nonlinear hyperelastic, transversely isotropic skeletal muscle constitutive law containing a deep tissue injury model was implemented in LS-DYNA. To demonstrate the feasibility of the entire modelling-simulation-analysis workflow and the fact that detailed, anatomically realistic, multi-muscle models are superior to state-of-the-art, fused-muscle models, an implicit dynamic FE analysis of 2-h bipedal stance is carried out. By analysing the potential volume of damaged muscle tissue after donning an optimally-fitted and a misfitted socket, i.e., a socket whose volume was isotropically shrunk by 10%, we were able to highlight the differences between the detailed individual- and fused-muscle models. The results of the bipedal stance simulation showed that peak stresses in the fused-muscle model were four times lower when compared to the multi-muscle model. The peak interface stress in the individual-muscle model, at the end of bipedal stance analysis, was 2.63 times lower than that in the deep tissues of the stump. At the end of the bipedal stance analysis using the misfitted socket, the fused-muscle model predicted that 7.65% of the residual limb volume was injured, while the detailed-model predicted 16.03%. The proposed approach is not only limited to modelling residual limbs but also has applications in predicting the impact of plastic surgery, for detailed forward-dynamics simulations of normal musculoskeletal systems.

Diffusion tensor imaging of human Achilles tendon by stimulated echo readout-segmented EPI (ste-RS-EPI)

PURPOSE

Healing, regeneration, and remodeling of the injured Achilles tendon are associated with notable changes in tendon architecture. However, assessing Achilles microstructural properties with conventional diffusion tension imaging (DTI) remains a challenge because of very short T₂ / <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML"> <mml:mrow><mml:msubsup><mml:mi>T</mml:mi> <mml:mn>2</mml:mn> <mml:mo>*</mml:mo></mml:msubsup> </mml:mrow> </mml:math> values of the tendon. Hence, the objective of this study was to develop a novel Achilles tendon DTI protocol for a non-invasive investigation of the changes of microstructural integrity in tendinopathy.

METHODS

A novel stimulated echo readout-segmented EPI (ste-RS-EPI) DTI sequence was proposed to achieve a TE of ∼14-20 ms for typical b-values of 400-800 s/mm² on clinical 3T MRI scanners. To further boost tendon MR signal, the Achilles was positioned at the magic angle (∼55 °) with respect to the scanner B₀ field. The sensitivity of the developed protocol was evaluated in 19 healthy participants and 6 patients with clinically confirmed tendinopathy.

RESULTS

Compared to spin echo RS-EPI DTI protocol, ste-RS-EPI provided an ∼100-200% increase in Achilles MR signal. Tendinopathic Achilles demonstrated a high degree of microstructural disruption based on DTI tractography analysis, with significantly lower (P < 0.05) axial diffusivity (1.20 ± 0.19 vs. 1.39 ± 0.10 × 10^-3 mm² /s), radial diffusivity (0.72 ± 0.11 vs. 0.81 ± 0.08 × 10^-3 mm² /s), and mean diffusivity (0.87 ± 0.14 vs. 1.00 ± 0.07 × 10^-3 mm² /s), but no significant difference in fractional anisotropy (0.38 ± 0.04 vs. 0.38 ± 0.05; P = 0.86).

CONCLUSION

Achilles tendon ste-RS-EPI DTI can non-invasively detect the tendinopathy-induced changes to microstructural integrity, consistent with the disruption of collagen arrangement and increased cellularity. This study demonstrated the robustness and sensitivity of the proposed protocol in Achilles tendinopathy.

Normalized STEAM-based diffusion tensor imaging provides a robust assessment of muscle tears in football players: preliminary results of a new approach to evaluate muscle injuries

Objectives

To assess acute muscle tears in professional football players by diffusion tensor imaging (DTI) and evaluate the impact of normalization of data.

Methods

Eight football players with acute lower limb muscle tears were examined. DTI metrics of the injured muscle and corresponding healthy contralateral muscle and of ROIs drawn in muscle tears (ROI_tear) in the corresponding healthy contralateral muscle (ROI_{hc_t}) in a healthy area ipsilateral to the injury (ROI_hi) and in a corresponding contralateral area (ROI_{hc_i}) were compared. The same comparison was performed for ratios of the injured (ROI_tear/ROI_hi) and contralateral sides (ROI_{hc_t}/ROI_{hc_i}). ANOVA, Bonferroni-corrected post-hoc and Student’s t-tests were used.

Results

Analyses of the entire muscle did not show any differences (p>0.05 each) except for axial diffusivity (AD; p=0.048). ROI_tear showed higher mean diffusivity (MD) and AD than ROI_{hc_t} (p<0.05). Fractional anisotropy (FA) was lower in ROI_tear than in ROI_hi and ROI_{hc_t} (p<0.05). Radial diffusivity (RD) was higher in ROI_tear than in any other ROI (p<0.05). Ratios revealed higher MD and RD and lower FA and reduced number and length of fibre tracts on the injured side (p<0.05 each).

Conclusions

DTI allowed a robust assessment of muscle tears in athletes especially after normalization to healthy muscle tissue.

Key Points

• STEAM-based DTI allows the investigation of muscle tears affecting professional football players.

• Fractional anisotropy and mean diffusivity differ between injured and healthy muscle areas.

• Only normalized data show differences of fibre tracking metrics in muscle tears.

• The normalization of DTI-metrics enables a more robust characterization of muscle tears.

Spontaneous mechanical and electrical activities of human calf musculature at rest assessed by repetitive single-shot diffusion-weighted MRI and simultaneous surface electromyography

PURPOSE

Assessment of temporal and spatial relations between spontaneous mechanical activities in musculature (SMAM) at rest as revealed by diffusion-weighted imaging (DWI) and electrical muscular activities in surface EMG (sEMG). Potential influences of static and radiofrequency magnetic fields on muscular activity on sEMG measurements at rest were examined systematically.

METHODS

Series of diffusion-weighted stimulated echo planar imaging were recorded with concurrent sEMG measurements. Electrical activities in sEMG were analyzed by non-parametric Friedman and two-sample Kolmogorov-Smirnov test. Direct correlation of both modalities was investigated by temporal mapping of electrical activity in sEMG to DWI repetition interval.

RESULTS

Electrical activities in sEMG and number of visible SMAMs in DWI showed a strong correlation (ρ = 0.9718). High accordance between sEMG activities and visible SMAMs in DWI in a near-surface region around sEMG electrodes was achieved. Characteristics of sEMG activities were almost similar under varying magnetic field conditions.

CONCLUSION

Visible SMAMs in DWI have shown a close and direct relation to concurrent signals recorded by sEMG. MR-related magnetic fields had no significant effects on findings in sEMG. Hence, appearance of SMAMs in DWI should not be considered as imaging artifact or as effects originating from the special conditions of MR examinations. Spatial and temporal distributions of SMAMs indicate characteristics of spontaneous (microscopic) mechanical muscular action at rest. Therefore, DWI techniques should be considered as non-invasive tools for studying physiology and pathophysiology of spontaneous activities in resting muscle. Magn Reson Med 79:2784-2794, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Improved olefinic fat suppression in skeletal muscle DTI using a magnitude-based dixon method

PURPOSE

To develop a method of suppressing the multi-resonance fat signal in diffusion-weighted imaging of skeletal muscle. This is particularly important when imaging patients with muscular dystrophies, a group of diseases which cause gradual replacement of muscle tissue by fat.

THEORY AND METHODS

The signal from the olefinic fat peak at 5.3 ppm can significantly confound diffusion-tensor imaging measurements. Dixon olefinic fat suppression (DOFS), a magnitude-based chemical-shift-based method of suppressing the olefinic peak, is proposed. It is verified in vivo by performing diffusion tensor imaging (DTI)-based quantification in the lower leg of seven healthy volunteers, and compared to two previously described fat-suppression techniques in regions with and without fat contamination.

RESULTS

In the region without fat contamination, DOFS produces similar results to existing techniques, whereas in muscle contaminated by subcutaneous fat signal moved due to the chemical shift artefact, it consistently showed significantly higher (P = 0.018) mean diffusivity (MD). Because fat presence lowers MD, this suggests improved fat suppression.

CONCLUSION

DOFS offers superior fat suppression and enhances quantitative measurements in the muscle in the presence of fat. DOFS is an alternative to spectral olefinic fat suppression. Magn Reson Med 79:152-159, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Skeletal muscle diffusion tensor-MRI fiber tracking: rationale, data acquisition and analysis methods, applications and future directions

The mechanical functions of muscles involve the generation of force and the actuation of movement by shortening or lengthening under load. These functions are influenced, in part, by the internal arrangement of muscle fibers with respect to the muscle's mechanical line of action. This property is known as muscle architecture. In this review, we describe the use of diffusion tensor (DT)-MRI muscle fiber tracking for the study of muscle architecture. In the first section, the importance of skeletal muscle architecture to function is discussed. In addition, traditional and complementary methods for the assessment of muscle architecture (brightness-mode ultrasound imaging and cadaver analysis) are presented. Next, DT-MRI is introduced and the structural basis for the reduced and anisotropic diffusion of water in muscle is discussed. The third section discusses issues related to the acquisition of skeletal muscle DT-MRI data and presents recommendations for optimal strategies. The fourth section discusses methods for the pre-processing of DT-MRI data, the available approaches for the calculation of the diffusion tensor and the seeding and propagating of fiber tracts, and the analysis of the tracking results to measure structural properties pertinent to muscle biomechanics. Lastly, examples are presented of how DT-MRI fiber tracking has been used to provide new insights into how muscles function, and important future research directions are highlighted. Copyright © 2016 John Wiley & Sons, Ltd.

In vivo measurement of membrane permeability and myofiber size in human muscle using time-dependent diffusion tensor imaging and the random permeable barrier model

The time dependence of the diffusion coefficient is a hallmark of tissue complexity at the micrometer level. Here we demonstrate how biophysical modeling, combined with a specifically tailored diffusion MRI acquisition performing diffusion tensor imaging (DTI) for varying diffusion times, can be used to determine fiber size and membrane permeability of muscle fibers in vivo. We describe the random permeable barrier model (RPBM) and its assumptions, as well as the details of stimulated echo DTI acquisition, signal processing steps, and potential pitfalls. We illustrate the RPBM method on a few pilot examples involving human subjects (previously published as well as new), such as revealing myofiber size derived from RPBM increase after training in a calf muscle, and size decrease with atrophy in shoulder rotator cuff muscle. Finally, we comment on the potential clinical relevance of our results. Copyright © 2016 John Wiley & Sons, Ltd.

In vivo diffusion MRS investigation of non-water molecules in biological tissues

Diffusion MRS of non-water molecules offers great potential in directly revealing various tissue microstructures and physiology at both cellular and subcellular levels. In brain, ¹ H diffusion MRS has been demonstrated as a new tool for probing normal tissue microstructures and their pathological changes. In skeletal muscle, ¹ H diffusion MRS could characterize slow and restricted intramyocellular lipid diffusion, providing a sensitive marker for metabolic alterations, while ³¹ P diffusion MRS can measure ATP and PCr diffusion, which may reflect the capacity of cellular energy transport, complementing the information from frequently used ³¹ P MRS in muscle. In intervertebral disk, ¹ H diffusion MRS can directly monitor extracellular matrix integrity by quantifying the mobility of macromolecules such as proteoglycans and collagens. In tumor tissue, ¹³ C diffusion MRS could probe intracellular glycolytic metabolism, while ¹ H diffusion MRS may separate the spectrally overlapped lactate and lipid resonances. In this review, recent diffusion MRS studies of these biologically relevant non-water molecules under normal and diseased conditions will be presented. Technical considerations for diffusion MRS experiments will be discussed. With advances in MRI hardware and diffusion methodology, diffusion MRS of non-water molecules is expected to provide increasingly valuable and biologically specific information on tissue microstructures and physiology, complementing the traditional diffusion MRI of small and ubiquitous water molecules. Copyright © 2016 John Wiley & Sons, Ltd.

Diffusion-weighted imaging outside the brain: Consensus statement from an ISMRM-sponsored workshop

The significant advances in magnetic resonance imaging (MRI) hardware and software, sequence design, and postprocessing methods have made diffusion-weighted imaging (DWI) an important part of body MRI protocols and have fueled extensive research on quantitative diffusion outside the brain, particularly in the oncologic setting. In this review, we summarize the most up-to-date information on DWI acquisition and clinical applications outside the brain, as discussed in an ISMRM-sponsored symposium held in April 2015. We first introduce recent advances in acquisition, processing, and quality control; then review scientific evidence in major organ systems; and finally describe future directions. J. Magn. Reson. Imaging 2016;44:521-540.

Diffusional kurtosis MRI of the lower leg: changes caused by passive muscle elongation and shortening

Diffusional kurtosis MRI (DKI) quantifies the deviation of water diffusion from a Gaussian distribution. We investigated the influence of passive elongation and shortening of the lower leg muscles on the DKI parameters D (diffusion coefficient) and K (kurtosis). After approval by the local ethics committee, eight healthy volunteers (age, 29.1 ± 2.9 years) underwent MRI of the lower leg at 3 T. Diffusion-weighted images were acquired with 10 different b values at three ankle positions (passive dorsiflexion 10°, neutral position 0°, passive plantar flexion 40°). Parametrical maps of D and K were obtained by voxel-wise fitting of the signal intensities using a non-linear Levenberg-Marquardt algorithm. D and K were measured in the tibialis anterior, medial and lateral gastrocnemius, and soleus muscles. In the neutral position, D and K values were in the range between 1.66-1.79 × 10(-3) mm(2) /s and 0.21-0.39, respectively. D and K increased with passive shortening, and decreased with passive elongation, which could also be illustrated on the parametrical maps. In dorsiflexion, D (p < 0.01) and K (p = 0.036) were higher in the tibialis anterior than in the medial gastrocnemius. In plantar flexion, the opposite was found for K (p = 0.035). DKI parameters in the lower leg muscles are significantly influenced by the ankle joint position, indicating that the diffusion of water molecules in skeletal muscle deviates from a Gaussian distribution depending on muscle tonus. Copyright © 2016 John Wiley & Sons, Ltd.

Techniques and applications of skeletal muscle diffusion tensor imaging: A review

Diffusion tensor imaging (DTI) is increasingly applied to study skeletal muscle physiology, anatomy, and pathology. The reason for this growing interest is that DTI offers unique, noninvasive, and potentially diagnostically relevant imaging readouts of skeletal muscle structure that are difficult or impossible to obtain otherwise. DTI has been shown to be feasible within most skeletal muscles. DTI parameters are highly sensitive to patient-specific properties such as age, body mass index (BMI), and gender, but also to more transient factors such as exercise, rest, pressure, temperature, and relative joint position. However, when designing a DTI study one should not only be aware of sensitivity to the above-mentioned factors but also the fact that the DTI parameters are dependent on several acquisition parameters such as echo time, b-value, and diffusion mixing time. The purpose of this review is to provide an overview of DTI studies covering the technical, demographic, and clinical aspects of DTI in skeletal muscles. First we will focus on the critical aspects of the acquisition protocol. Second, we will cover the reported normal variance in skeletal muscle diffusion parameters, and finally we provide an overview of clinical studies and reported parameter changes due to several (patho-)physiological conditions.

Addressing spontaneous signal voids in repetitive single-shot DWI of musculature: spatial and temporal patterns in the calves of healthy volunteers and consideration of unintended muscle activities as underlying mechanism

Single-shot diffusion-weighted MRI sensitive to different types of incoherent motion inside tissue shows sporadic signal voids with a considerable size (>1 cm) in calf musculature at rest. Spatial and temporal patterns of these signal voids and their dependence on measurement conditions were tested systematically in order to obtain more insight into the underlying mechanism. Lower leg muscles of 10 healthy subjects were examined by recording series of 1000 echo-planar single-shot scans with repetition time 500 ms and b-value 100 s/mm(2) . Effects of strength and orientation of motion sensitization gradients and of repetition times were analysed. Potential influences of arterial blood pulsations and positioning of the subject were studied. Comparison of calf muscle groups showed more frequent signal voids in gastrocnemius and soleus muscle compared with tibialis muscles. Large inter-individual variance in the total number of signal voids visible in a transverse slice of the lower leg was observed (minimum 40/1000 scans; maximum >550/1000 scans). Typical sizes of the affected muscular areas ranged from 1.5 to 2.5 cm in the transverse and from 1.5 to 7 cm in the head-feet direction. Signal voids occurred nearly independent of the cardiac phase and with similar frequencies for supine and prone positions. Resting calf muscles show spontaneous signal voids in single-shot DWI at low b-values with an irregular temporal and spatial pattern. Values of mean diffusivity, diffusion tensor parameters, and IVIM-derived perfusion are expected to be clearly distorted by such signal voids if no rejection of affected data is applied. Several potential causes for the signal voids are discussed. The most probable explanation for the phenomenon is seen in the occurrence of spontaneous incoherent mechanical activity in musculature based on weak muscle fibre contractions. If this is the case it opens up a new field for studies on the physiological role and regulation of these unintended muscle activities.

Spatial variations in magnetic resonance-based diffusion of articular cartilage in knee osteoarthritis

PURPOSE

To evaluate a pulse sequence combining stimulated echo diffusion preparation with a 3D segmented spoiled gradient echo (SPGR) acquisition for diffusion tensor imaging (DTI) of knee cartilage in healthy and osteoarthritis (OA) populations for early diagnosis and characterization of OA.

METHODS

Diffusion-weighted images of 40 subjects (20 healthy, 20 OA) at baseline and 20 subjects (10 healthy, 10 OA) at one year were obtained. The subjects were classified according to Kellgren Lawrence (KL) and whole organ magnetic resonance imaging scoring (WORMS) method acquired at 3 T. Cartilage full thickness and laminar mean diffusivity (MD) and fractional anisotropy (FA) values were quantified. The reproducibility of MD and FA values was assessed in five healthy human subjects based on test-retest scans.

RESULTS

In general, the full thickness MD values were higher in subjects with knee OA compared to healthy controls in both the baseline and follow up cohort. Laminar analysis MD and FA results were significantly different (p<0.05) between the bone-articular and articular layer with the articular layer having higher MD and lower FA value compared to the bone layer. The global reproducibility error was 6.5% for MD and 11.6% for FA.

CONCLUSION

The diffusion-weighted stimulated echo-based sequence may be used as a valuable tool for early diagnosis and characterization of knee OA at 3 T in the future.

Time-dependent diffusion in skeletal muscle with the random permeable barrier model (RPBM): application to normal controls and chronic exertional compartment syndrome patients

The purpose of this work was to carry out diffusion tensor imaging (DTI) at multiple diffusion times Td in skeletal muscle in normal subjects and chronic exertional compartment syndrome (CECS) patients and analyze the data with the random permeable barrier model (RPBM) for biophysical specificity. Using an institutional review board approved HIPAA-compliant protocol, seven patients with clinical suspicion of CECS and eight healthy volunteers underwent DTI of the calf muscle in a Siemens MAGNETOM Verio 3 T scanner at rest and after treadmill exertion at four different T(d) values. Radial diffusion values λ(rad) were computed for each of seven different muscle compartments and analyzed with RPBM to produce estimates of free diffusivity D(0), fiber diameter a, and permeability κ. Fiber diameter estimates were compared with measurements from literature autopsy reference for several compartments. Response factors (post/pre-exercise ratios) were computed and compared between normal controls and CECS patients using a mixed-model two-way analysis of variance. All subjects and muscle compartments showed nearly time-independent diffusion along and strongly time-dependent diffusion transverse to the muscle fibers. RPBM estimates of fiber diameter correlated well with corresponding autopsy reference. D(0) showed significant (p < 0.05) increases with exercise for volunteers, and a increased significantly (p < 0.05) in volunteers. At the group level, response factors of all three parameters showed trends differentiating controls from CECS patients, with patients showing smaller diameter changes (p = 0.07), and larger permeability increases (p = 0.07) than controls. Time-dependent diffusion measurements combined with appropriate tissue modeling can provide enhanced microstructural specificity for in vivo tissue characterization. In CECS patients, our results suggest that high-pressure interfiber edema elevates free diffusion and restricts exercise-induced fiber dilation. Such specificity may be useful in differentiating CECS from other disorders or in predicting its response to either physical therapy or fasciotomy.

Comparison of twice refocused spin echo versus stimulated echo diffusion tensor imaging for tracking muscle fibers

PURPOSE

To compare the precision of measuring the pennation angle and fiber length in the vastus lateralis (VL) using two distinctly different diffusion tensor imaging (DTI) sequences.

MATERIALS AND METHODS

We imaged the thigh of 10 normal subjects on a 3T magnetic resonance (MR) imager with twice refocused spin echo (TRSE) and stimulated echo (STEAM) DTI-MRI techniques. Both techniques took the same total acquisition time and employed the same diffusion weighting and gradient directions. Using the diffusion tensor images produced by each sequence, muscle fiber bundles were tracked from the aponeurosis by following the first eigenvector of the diffusion tensor. From these tracks we calculated the pennation angle and fiber length.

RESULTS

The STEAM acquisition resulted in significantly higher signal-to-noise ratio (SNR), lower apparent diffusion coefficient (ADC), higher fractional anisotropy (FA) values, and longer fibers than TRSE. Although no difference in the pennation angle between the two acquisitions was found, the TRSE sequence had a significantly greater within-subject dispersion in the pennation angle of tracked fibers, which may indicate a reduction in the coherence of fiber bundles.

CONCLUSION

DTI of muscle using a STEAM acquisition resulted in significant improvements in the SNR and FA, resulting in tracking a larger number of muscle fiber bundles over longer distances and with less within-subject dispersion.

Fast low-angle shot diffusion tensor imaging with stimulated echo encoding in the muscle of rabbit shank

In the past, spin-echo (SE) echo planar imaging(EPI)-based diffusion tensor imaging (DTI) has been widely used to study the fiber structure of skeletal muscles in vivo. However, this sequence has several shortcomings when measuring restricted diffusion in small animals, such as its sensitivity to susceptibility-related distortions and a relatively short applicable diffusion time. To address these limitations, in the current work, a stimulated echo acquisition mode (STEAM) MRI technique, in combination with fast low-angle shot (FLASH) readout (turbo-STEAM MRI), was implemented and adjusted for DTI in skeletal muscles. Signal preparation using stimulated echoes enables longer effective diffusion times, and thus the detection of restricted diffusion within muscular tissue with intracellular distances up to 100 µm. Furthermore, it has a reduced penalty for fast T2 muscle signal decay, but at the expense of 50% signal loss compared with a SE preparation. Turbo-STEAM MRI facilitates high-resolution DTI of skeletal muscle without introducing susceptibility-related distortions. To demonstrate its applicability, we carried out rabbit in vivo measurements on a human whole-body 3 T scanner. DTI parameters of the shank muscles were extracted, including the apparent diffusion coefficient, fractional anisotropy, eigenvalues and eigenvectors. Eigenvectors were used to calculate maps of structural parameters, such as the planar index and the polar coordinates θ and ϕ of the largest eigenvector. These parameters were compared between three muscles. θ and ϕ showed clear differences between the three muscles, reflecting different pennation angles of the underlying fiber structures. Fiber tractography was performed to visualize and analyze the architecture of skeletal pennate muscles. Optimization of tracking parameters and utilization of T2 -weighted images for improved muscle boundary detection enabled the determination of additional parameters, such as the mean fiber length. The presented results support the applicability of turbo-STEAM MRI as a promising method for quantitative DTI analysis and fiber tractography in skeletal muscles.

DTI of human skeletal muscle: the effects of diffusion encoding parameters, signal-to-noise ratio and T2 on tensor indices and fiber tracts

In this study, we have performed simulations to address the effects of diffusion encoding parameters, signal-to-noise ratio (SNR) and T2 on skeletal muscle diffusion tensor indices and fiber tracts. Where appropriate, simulations were corroborated and validated by in vivo diffusion tensor imaging (DTI) of human skeletal muscle. Specifically, we have addressed: (i) the accuracy and precision of the diffusion parameters and eigenvectors at different SNR levels; (ii) the effects of the diffusion gradient direction encoding scheme; (iii) the optimal b value for diffusion tensor estimation; (iv) the effects of changes in skeletal muscle T2; and, finally, the influence of SNR on fiber tractography and derived (v) fiber lengths, (vi) pennation angles and (vii) fiber curvatures. We conclude that accurate DTI of skeletal muscle requires an SNR of at least 25, a b value of between 400 and 500 s/mm(2), and data acquired with at least 12 diffusion gradient directions homogeneously distributed on half a sphere. Furthermore, for DTI studies focusing on skeletal muscle injury or pathology, apparent changes in the diffusion parameters need to be interpreted with great care in view of the confounding effects of T2, particularly for moderate to low SNR values.

Multiple-echo diffusion tensor acquisition technique (MEDITATE) on a 3T clinical scanner

This article describes the concepts and implementation of an MRI method, the multiple-echo diffusion tensor acquisition technique (MEDITATE), which is capable of acquiring apparent diffusion tensor maps in two scans on a 3T clinical scanner. In each MEDITATE scan, a set of RF pulses generates multiple echoes, the amplitudes of which are diffusion weighted in both magnitude and direction by a pattern of diffusion gradients. As a result, two scans acquired with different diffusion weighting strengths suffice for accurate estimation of diffusion tensor imaging (DTI) parameters. The MEDITATE variation presented here expands previous MEDITATE approaches to adapt to the clinical scanner platform, such as exploiting longitudinal magnetization storage to reduce T2 weighting. Fully segmented multi-shot Cartesian encoding is used for image encoding. MEDITATE was tested on isotropic (agar gel), anisotropic diffusion phantoms (asparagus) and in vivo skeletal muscle in healthy volunteers with cardiac gating. Comparisons of accuracy were performed with standard twice-refocused spin echo (TRSE) DTI in each case and good quantitative agreement was found between diffusion eigenvalues, mean diffusivity and fractional anisotropy derived from TRSE DTI and from the MEDITATE sequence. Orientation patterns were correctly reproduced in both isotropic and anisotropic phantoms, and approximately for in vivo imaging. This illustrates that the MEDITATE method of compressed diffusion encoding is feasible on the clinical scanner platform. With future development and employment of appropriate view-sharing image encoding, this technique may be used in clinical applications requiring time-sensitive acquisition of DTI parameters such as dynamical DTI in muscle.

Stimulated echo diffusion tensor imaging and SPAIR T2 -weighted imaging in chronic exertional compartment syndrome of the lower leg muscles

PURPOSE

To evaluate the performance of diffusion tensor imaging (DTI) in the evaluation of chronic exertional compartment syndrome (CECS) as compared to T2 -weighted (T2w) imaging.

MATERIALS AND METHODS

Using an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant protocol, spectral adiabatic inversion recovery (SPAIR) T2w imaging and stimulated echo DTI were applied to eight healthy volunteers and 14 suspected CECS patients before and after exertion. Longitudinal and transverse diffusion eigenvalues, mean diffusivity (MD), and fractional anisotropy (FA) were measured in seven calf muscle compartments, which in patients were classified by their response on T2w: normal (<20% change), and CECS (>20% change). Mixed model analysis of variance compared subject groups and compartments in terms of response factors (post/pre-exercise ratios) of DTI parameters.

RESULTS

All diffusivities significantly increased (P < 0.0001) and FA decreased (P = 0.0014) with exercise. Longitudinal diffusion responses were significantly smaller than transversal diffusion responses (P < 0.0001). Nineteen of 98 patient compartments were classified as CECS on T2w. MD increased by 3.8 ± 3.4% (volunteer), 7.4 ± 4.2% (normal), and 9.1 ± 7.0% (CECS) with exercise.

CONCLUSION

DTI shows promise as an ancillary imaging method in the diagnosis and understanding of the pathophysiology in CECS. Future studies may explore its utility in predicting response to treatment.