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Assessment of cognitive and neural recovery in survivors of pediatric brain tumors in a pilot clinical trial using metformin. Nat Med 2020; 26:1285-1294. [PMID: 32719487 DOI: 10.1038/s41591-020-0985-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 06/19/2020] [Indexed: 02/06/2023]
Abstract
We asked whether pharmacological stimulation of endogenous neural precursor cells (NPCs) may promote cognitive recovery and brain repair, focusing on the drug metformin, in parallel rodent and human studies of radiation injury. In the rodent cranial radiation model, we found that metformin enhanced the recovery of NPCs in the dentate gyrus, with sex-dependent effects on neurogenesis and cognition. A pilot double-blind, placebo-controlled crossover trial was conducted (ClinicalTrials.gov, NCT02040376) in survivors of pediatric brain tumors who had been treated with cranial radiation. Safety, feasibility, cognitive tests and MRI measures of white matter and the hippocampus were evaluated as endpoints. Twenty-four participants consented and were randomly assigned to complete 12-week cycles of metformin (A) and placebo (B) in either an AB or BA sequence with a 10-week washout period at crossover. Blood draws were conducted to monitor safety. Feasibility was assessed as recruitment rate, medication adherence and procedural adherence. Linear mixed modeling was used to examine cognitive and MRI outcomes as a function of cycle, sequence and treatment. We found no clinically relevant safety concerns and no serious adverse events associated with metformin. Sequence effects were observed for all cognitive outcomes in our linear mixed models. For the subset of participants with complete data in cycle 1, metformin was associated with better performance than placebo on tests of declarative and working memory. We present evidence that a clinical trial examining the effects of metformin on cognition and brain structure is feasible in long-term survivors of pediatric brain tumors and that metformin is safe to use and tolerable in this population. This pilot trial was not intended to test the efficacy of metformin for cognitive recovery and brain growth, but the preliminary results are encouraging and warrant further investigation in a large multicenter phase 3 trial.
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Krainik A, Villien M, Troprès I, Attyé A, Lamalle L, Bouvier J, Pietras J, Grand S, Le Bas JF, Warnking J. Functional imaging of cerebral perfusion. Diagn Interv Imaging 2013; 94:1259-78. [PMID: 24011870 DOI: 10.1016/j.diii.2013.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The functional imaging of perfusion enables the study of its properties such as the vasoreactivity to circulating gases, the autoregulation and the neurovascular coupling. Downstream from arterial stenosis, this imaging can estimate the vascular reserve and the risk of ischemia in order to adapt the therapeutic strategy. This method reveals the hemodynamic disorders in patients suffering from Alzheimer's disease or with arteriovenous malformations revealed by epilepsy. Functional MRI of the vasoreactivity also helps to better interpret the functional MRI activation in practice and in clinical research.
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Affiliation(s)
- A Krainik
- Clinique universitaire de neuroradiologie et IRM, CHU de Grenoble, CS 10217, 38043 Grenoble cedex, France; Inserm U836, université Joseph-Fourier, site santé, chemin Fortuné-Ferrini, 38706 La Tronche cedex, France; UMS IRMaGe, unité IRM 3T recherche, CHU de Grenoble, CS 10217, 38043 Grenoble cedex 9, France.
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Rijbroek A, Boellaard R, Vriens EM, Lammertsma AA, Rauwerda JA. Comparison of transcranial Doppler ultrasonography and positron emission tomography using a three-dimensional template of the middle cerebral artery. Neurol Res 2013; 31:52-9. [DOI: 10.1179/174313208x325191] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Kamano H, Yoshiura T, Hiwatashi A, Abe K, Togao O, Yamashita K, Honda H. Arterial spin labeling in patients with chronic cerebral artery steno-occlusive disease: correlation with (15)O-PET. Acta Radiol 2013; 54:99-106. [PMID: 23091237 DOI: 10.1258/ar.2012.120450] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heterogeneity of arterial transit time due to cerebral artery steno-occlusive lesions hampers accurate regional cerebral blood flow measurement by arterial spin labeling (ASL). PURPOSE To assess the feasibility of regional cerebral blood flow measurement by ASL with multiple-delay time sampling in patients with steno-occlusive diseases by comparing with positron emission tomography (PET), and to determine whether regional arterial transit time measured by this ASL technique is correlated with regional mean transit time, a PET index of perfusion pressure. MATERIAL AND METHODS Sixteen patients with steno-occlusive diseases received both ASL and (15)O-PET. The mean regional cerebral blood flow measured by ASL and PET, regional arterial transit time by ASL, and regional mean transit time by PET were obtained by a region-of-interest analysis. Correlation between regional cerebral blood flow by ASL and that by PET, and correlation between regional arterial transit time by ASL and regional mean transit time by PET were tested using Pearson's correlation coefficient for both absolute and relative values. A multivariate regression analysis was performed to test whether regional arterial transit time by ASL was a significant contributor in modeling regional mean transit time by PET after controlling the effect of regional cerebral blood flow by ASL. RESULTS A significant positive correlation was found between regional cerebral blood flow by ASL and that by PET for both absolute (r = 0.520, P < 0.0001) and relative (r = 0.691, P < 0.0001) values. A significant positive correlation was found between regional arterial transit time by ASL and regional mean transit time by PET both for absolute (r = 0.369, P = 0.0002) and relative (r = 0.443, P < 0.0001) values. The regression analysis revealed that regional arterial transit time by ASL was a significant contributor in modeling regional mean transit time by PET after controlling regional cerebral blood flow by ASL (P = 0.0011). CONCLUSION The feasibility of regional cerebral blood flow measurement using ASL with multiple-delay time sampling was confirmed in patients with cerebral artery steno-occlusive diseases. Moreover, it was suggested that mapping of regional arterial transit time has the potential to detect hemodynamic impairment.
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Affiliation(s)
| | | | | | | | - Osamu Togao
- Department of Molecular Imaging and Diagnosis, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Enmi JI, Kudomi N, Hayashi T, Yamamoto A, Iguchi S, Moriguchi T, Hori Y, Koshino K, Zeniya T, Jon Shah N, Yamada N, Iida H. Quantitative assessment of regional cerebral blood flow by dynamic susceptibility contrast-enhanced MRI, without the need for arterial blood signals. Phys Med Biol 2012; 57:7873-92. [DOI: 10.1088/0031-9155/57/23/7873] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Peisker T, Bartoš A, Skoda O, Ibrahim I, Kalvach P. Impact of aging on cerebral vasoregulation and parenchymal integrity. J Neurol Sci 2010; 299:112-5. [PMID: 20884015 DOI: 10.1016/j.jns.2010.08.064] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 08/27/2010] [Indexed: 11/16/2022]
Abstract
UNLABELLED Sufficient vasodilatory and vasoconstrictive reactivity of cerebral arterioles is an important prerequisite for adequate capillary perfusion. To appreciate its capacity during aging and to elucidate its impact on parenchymal integrity we undertook a correlation using ultrasonography and brain MRI. Sixty healthy persons with no stenoses in the carotid and vertebral arteries were examined by transcranial Doppler to assess middle cerebral artery mean flow velocities (MFV) at rest, after 30 s apnea and after 90 s hyperventilation. Young persons, N=20, with a mean age of 24.8 (20-32) were compared with the middle aged, N=20, 54.8 (40-63) and elderly, N=20, 76.2 (69-84). A different cohort of 40 elderly persons, with a mean age of 68.4 (57-85) were evaluated also by MRI using FLAIR and T2-weighted sequences. Their extent of leukoaraiosis measured by the Fazekas scale was correlated with their vasoregulatory capacity. RESULTS The steady state MFV in young persons, 71 cm/sec, decreases to 48.1 and to 44.9 cm/sec in the middle and the old aged. The post-apnoic vasodilatation in young persons accelerates the MCA blood velocity by 41.7%, while in middle and old age only by 37.6 and 32.9% respectively. The MCA deceleration post-hyperventilation by 50.2% in young people decreases to 39.1% and to 29.7% respectively in the older categories. The correlation of periventricular hyperintensities and deep white matter lesions was found highest with the index of resistance (0.45, p<0.05) while with the apnoic acceleration and hyperventilatory deceleration it was minimal (0.01 and 0.08 respectively). CONCLUSION The extent of vasoregulatory capacity during aging decreases along with the decreasing basic MFV. Its effect on the initial stages of leukoaraiosis is minimal.
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Affiliation(s)
- Tomáš Peisker
- Department of Neurology, Charles University, 3rd Medical Faculty, FNKV, Šrobárova 50, 100 34 Prague 10, Czech Republic.
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Kosior JC, Smith MR, Kosior RK, Frayne R. Cerebral blood flow estimation in vivo using local tissue reference functions. J Magn Reson Imaging 2009; 29:183-8. [DOI: 10.1002/jmri.21605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Bokkers RPH, van Laar PJ, van de Ven KCC, Kapelle LJ, Klijn CJM, Hendrikse J. Arterial spin-labeling MR imaging measurements of timing parameters in patients with a carotid artery occlusion. AJNR Am J Neuroradiol 2008; 29:1698-703. [PMID: 18701581 DOI: 10.3174/ajnr.a1232] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Arterial spin-labeling (ASL) with image acquisition at multiple delay times can be exploited in perfusion MR imaging to visualize and quantify the temporal dynamics of arterial blood inflow. In this study, we investigated the consequences of an internal carotid artery (ICA) occlusion and collateral blood flow on regional timing parameters. MATERIALS AND METHODS Seventeen functionally independent patients with a symptomatic ICA occlusion (15 men, 2 women; mean age, 57 years) and 29 sex- and age-matched control subjects were investigated. ASL at multiple delay times was used to quantify regional cerebral blood flow (CBF) and the transit and trailing edge times (arterial timing parameters) reflecting, respectively, the beginning and end of the labeled bolus. Intra-arterial digital subtraction angiography and MR angiography were used to grade collaterals. RESULTS In the hemisphere ipsilateral to the ICA occlusion, the CBF was lower in the anterior frontal (31 +/- 4 versus 47 +/- 3 mL/min/100 g, P < .01), posterior frontal (39 +/- 4 versus 55 +/- 2 mL/min/100 g, P < .01), and frontal parietal region (49 +/- 3 versus 61 +/- 3 mL/min/100 g, P = .04) than that in control subjects. The trailing edge of the frontal-parietal region was longer in the hemisphere ipsilateral to the ICA occlusion compared with that in control subjects (2225 +/- 167 versus 1593 +/- 35 ms, P < .01). In patients with leptomeningeal collateral flow, the trailing edge was longer in the anterior frontal region (2436 +/- 275 versus 1648 +/- 201 ms, P = .03) and shorter in the occipital region (1815 +/- 128 versus 2388 +/- 203 ms, P = .04), compared with patients without leptomeningeal collaterals. CONCLUSION Regional assessment of timing parameters with ASL may provide valuable information on the cerebral hemodynamic status. In patients with leptomeningeal collaterals, the most impaired territory was found in the frontal lobe.
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Affiliation(s)
- R P H Bokkers
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands.
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Kosior JC, Kosior RK, Frayne R. Robust dynamic susceptibility contrast MR perfusion using 4D nonlinear noise filters. J Magn Reson Imaging 2007; 26:1514-22. [DOI: 10.1002/jmri.21219] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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van Osch MJP, van der Grond J, Bakker CJG. Partial volume effects on arterial input functions: shape and amplitude distortions and their correction. J Magn Reson Imaging 2006; 22:704-9. [PMID: 16261570 DOI: 10.1002/jmri.20455] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
For quantification of perfusion values from a bolus-tracking MRI experiment, the measurement of an arterial input function (AIF) is necessary. Gradient-echo (GE) sequences are commonly used for this type of experiment because they offer a high signal-to-noise ratio (SNR) and the potential to quantify the concentration of contrast agent. Measurements of calibration curves for Gd-DTPA in human blood have shown a quadratic relation between the DeltaR(2)* and the concentration of contrast agent, and a linear relationship between phase changes and the concentration of contrast agent. However, for in vivo studies the spatial resolution is usually limited, which leads to partial volume effects. Partial volume effects result in a complex sum of signal arising from the tissue outside the vessel and a contrast agent concentration-dependent blood signal. Ignoring the presence of partial volume effects can lead to an overestimation or underestimation of the contrast agent concentration, depending on the experimental conditions. Correction for partial volume effects is feasible in arteries that are parallel to the main magnetic field by estimation and subtraction of the static signal of the surrounding tissue. Patient studies showed a large variation due to the AIF measurements, but it has also been shown that this influence can be minimized by correction for partial volume effects.
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Affiliation(s)
- Matthias J P van Osch
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Hendrikse J, van Osch MJP, Rutgers DR, Bakker CJG, Kappelle LJ, Golay X, van der Grond J. Internal Carotid Artery Occlusion Assessed at Pulsed Arterial Spin-labeling Perfusion MR Imaging at Multiple Delay Times. Radiology 2004; 233:899-904. [PMID: 15486211 DOI: 10.1148/radiol.2333031276] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Magnetic resonance (MR) imaging with pulsed arterial spin labeling (ASL) was performed at six different inversion times in nine patients with internal carotid artery (ICA) occlusion and in 11 control subjects. The hospital's commission on scientific research on human subjects approved the study protocol, and all study subjects gave informed consent. Cerebral blood flow (CBF) in the middle cerebral artery territories was calculated from the combined signal intensities measured with ASL at the multiple inversion times. In the patients with ICA occlusion, mean CBF values were decreased in the gray matter of the hemisphere ipsilateral to the occlusion, as compared with values in the gray matter of the contralateral hemisphere (P < .05) and with values in the gray matter of the control subjects (P < .05). Quantification of CBF with ASL at multiple inversion times can compensate for the blood transit delays in patients with ICA occlusion.
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Affiliation(s)
- Jeroen Hendrikse
- Department of Radiology (Hp E 01.132), University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
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Kavec M, Usenius JP, Tuunanen PI, Rissanen A, Kauppinen RA. Assessment of cerebral hemodynamics and oxygen extraction using dynamic susceptibility contrast and spin echo blood oxygenation level-dependent magnetic resonance imaging: applications to carotid stenosis patients. Neuroimage 2004; 22:258-67. [PMID: 15110016 DOI: 10.1016/j.neuroimage.2004.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Revised: 01/05/2004] [Accepted: 01/05/2004] [Indexed: 11/23/2022] Open
Abstract
Blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) has been recently used to quantify cerebral blood volume (CBV) and oxygen extraction ratio (OER). In the present study, we have exploited the intravascular BOLD model to assess gray matter (GM) OER at hemispheric level using parenchymal T(2) and CBV data at 1.5 T, obtained by single spin echo and dynamic susceptibility contrast (DSC) perfusion MRI, respectively. An OER of 0.40 +/- 0.07 was determined in gray matter for control subjects. A group of carotid stenosis (CS) patients (n = 22) was examined by multiparametric MRI. The degree of CS was determined by contrast agent-enhanced magnetic resonance angiography. Within the group, eight cases with <70% narrowing of a carotid lumen, nine cases with 70-99%, and five cases with complete occlusion of either carotid arteries were found. DSC MRI revealed abnormalities in 14 patients in dynamic parameters of perfusion images. These included four cases with elevated hemispheric gray matter CBV ipsilateral to the stenosis, above 2 SD of the level determined in control subjects. These four patients showed large variation in the degree of stenosis. We also found three cases with ipsilateral gray matter CBV below 2 SD of the control value, two of these with >70% stenosis. Gray matter OER ipsilateral to the stenosis was above 2 SD of the control range in eight CS patients, three of these showing also high CBV. Use of the present approach to determine OER for the assessment of hemodynamic adaptations in CS patients is discussed in the light of documented hemodynamic adaptations to carotid stenosis.
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Affiliation(s)
- Martin Kavec
- Department of Biomedical NMR and National Bio-NMR Facility, A.I. Virtanen Institute, University of Kuopio, Kuopio, Finland
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