[18F]Florbetapir PET/MR imaging to assess demyelination in multiple sclerosis

The Study of Remyelinating Therapies in Multiple Sclerosis: Visual Outcomes as a Window Into Repair

INTRODUCTION

Amelioration of disability in multiple sclerosis requires the development of complementary therapies that target neurodegeneration and promote repair. Remyelination is a promising neuroprotective strategy that may protect axons from damage and subsequent neurodegeneration.

METHODS

A review of key literature plus additional targeted search of PubMed and Google Scholar was conducted.

RESULTS

There has been a rapid expansion of clinical trials studying putative remyelinating candidates, but further growth of the field is limited by the lack of consensus on key aspects of trial design. We have not yet defined the ideal study population, duration of therapy, or the appropriate outcome measures to detect remyelination in humans. The varied natural history of multiple sclerosis, coupled with the short time frame of phase II clinical trials, requires that we develop and validate biomarkers of remyelination that can serve as surrogate endpoints in clinical trials.

CONCLUSIONS

We propose that the visual system may be the most well-suited and validated model for the study potential remyelinating agents. In this review, we discuss the pathophysiology of demyelination and summarize the current clinical trial landscape of remyelinating agents. We present some of the challenges in the study of remyelinating agents and discuss current potential biomarkers of remyelination and repair, emphasizing both established and emerging visual outcome measures.

Simultaneous assessment of blood flow and myelin content in the brain white matter with dynamic [11 C]PiB PET: a test-retest study in healthy controls

BACKGROUND

Exploring the relationship between oxygen supply and myelin damage would benefit from a simultaneous quantification of myelin and cerebral blood flow (CBF) in the brain's white matter (WM). To validate an analytical method for quantifying both CBF and myelin content in the WM using dynamic [11C]PiB positron emission tomography (PET).

METHODS

A test-retest study was performed on eight healthy subjects who underwent two consecutive dynamic [11 C]PiB-PET scans. Three quantitative approaches were compared: simplified reference tissue model 2 (SRTM2), LOGAN graphical model, and standardized uptake value ratio (SUVR). The sensitivity of methods to the size of the region of interest was explored by simulating lesion masks obtained from 36 subjects with multiple sclerosis. Reproducibility was assessed using the relative difference and interclass correlation coefficient. Repeated measures correlations were used to test for cross-correlations between metrics.

RESULTS

Among the CBF measures, the relative delivery (R1) of the simplified reference tissue model 2 (SRTM2) displayed the best reproducibility in the white matter, with a strong influence of the size of regions analyzed, the test-retest variability being below 10% for regions above 68 mm3 in the supratentorial white matter. [11C]PiB PET-derived proxies of CBF demonstrated lower perfusion of white matter compared to grey matter with an overall ratio equal to 1.71 ± 0.09 when the SRTM2-R1 was employed. Tissue binding in the white matter was well estimated by the Logan graphical model through estimation of the distribution volume ratio (LOGAN-DVR) and SRTM2 distribution volume ratio (SRTM2-DVR), with test-retest variability being below 10% for regions exceeding 106 mm3 for LOGAN-DVR and 300 mm3 for SRTM2-DVR. SRTM2-DVR provided a better contrast between white matter and grey matter. The interhemispheric variability was also dependent on the size of the region analyzed, being below 10% for regions above 103 mm3 for SRTM2-R1 and above 110 mm3 for LOGAN-DVR. Whereas the 1 to 8-minute standardized uptake value ratio (SUVR1-8) showed an intermediary reproducibility for CBF assessment, SUVR0-2 for perfusion or SUVR50-70 for tissue binding showed poor reproducibility and correlated only mildly with SRTM2-R1 and LOGAN-DVR estimations respectively.

CONCLUSIONS

[11C]PiB PET imaging can simultaneously quantify perfusion and myelin content in WM diseases associated with focal lesions. For longitudinal studies, SRTM2-R1 and DVR should be preferred over SUVR for the assessment of regional CBF and myelin content, respectively.

TRIAL REGISTRATION

European Union Clinical Trials Register EUDRACT; EudraCT Number: 2008-004174-40; Date: 2009-03-06; https//www.clinicaltrialsregister.eu ; number 2008-004174-40.

Synthesis and biological evaluation of radioiodinated benzoxazole and benzothiazole derivatives for imaging myelin in multiple sclerosis

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that results from destruction of the myelin sheath. Due to heterogeneity of the symptoms and course of MS, periodic monitoring of disease activity is important for diagnosis and treatment. In the present study, we synthesized four radioiodinated benzoxazole (BO) and benzothiazole (BT) derivatives, and evaluated their utility as novel myelin imaging probes for single photon emission computed tomography (SPECT). In a biodistribution study using normal mice, three compounds ([125I]BO-1, [125I]BO-2, and [125I]BT-2) displayed moderate brain uptake (2.7, 2.9, and 2.8% ID/g, respectively) at 2 min postinjection. On ex vivo autoradiography using normal mice, [125I]BO-2 showed the most preferable ratio of radioactivity accumulation in white matter (myelin-rich region) versus gray matter (myelin-deficient region). In addition, the radioactivity of [125I]BO-2 was reduced in the lysophosphatidylcholine-induced demyelination region. In conclusion, [123I]BO-2 demonstrated the fundamental characteristics of a myelin imaging probe for SPECT.

Remyelination in the Central Nervous System

The inability of the mammalian central nervous system (CNS) to undergo spontaneous regeneration has long been regarded as a central tenet of neurobiology. However, while this is largely true of the neuronal elements of the adult mammalian CNS, save for discrete populations of granule neurons, the same is not true of its glial elements. In particular, the loss of oligodendrocytes, which results in demyelination, triggers a spontaneous and often highly efficient regenerative response, remyelination, in which new oligodendrocytes are generated and myelin sheaths are restored to denuded axons. Yet remyelination in humans is not without limitation, and a variety of demyelinating conditions are associated with sustained and disabling myelin loss. In this work, we will (1) review the biology of remyelination, including the cells and signals involved; (2) describe when remyelination occurs and when and why it fails, including the consequences of its failure; and (3) discuss approaches for therapeutically enhancing remyelination in demyelinating diseases of both children and adults, both by stimulating endogenous oligodendrocyte progenitor cells and by transplanting these cells into demyelinated brain.

A Graph Convolutional Network Based on Univariate Neurodegeneration Biomarker for Alzheimer's Disease Diagnosis

OBJECTIVE

Alzheimer's disease (AD) is a progressive and irreversible neurodegenerative disease that is not easily detectable in the early stage. This study proposed an efficient method of applying a graph convolutional network (GCN) on the early prediction of AD.

METHODS

We proposed a univariate neurodegeneration biomarker (UNB) based GCN semi-supervised classification framework. We generated UNB by comparing the similarity of individual morphological atrophy pattern and the atrophy pattern of [Formula: see text] AD group according to the brain morphological abnormalities induced by AD. For the GCN semi-supervised classification model, we took the UNBs of individuals as the features of nodes and constructed the weight of edges according to the similarity of phenotypic information between individuals, which explored the essential features of individuals through spectral graph convolution. The attention module was constructed and embedded into the GCN framework, which may refine the input morphological features to highlight the main impact of AD on the cerebral cortex and weaken the instability caused by individual diversities, thereby identifying the significant ROIs affected by AD and improving the classification accuracy.

RESULTS

We tested the UNB-GCN framework on the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. The estimated minimum sample sizes were 156, 349 and 423 for the longitudinal [Formula: see text] AD, [Formula: see text] mild cognitive impairment (MCI) and [Formula: see text] cognitively unimpaired (CU) groups, respectively. And the proposed UNB-GCN framework combined with the attention module can effectively improve the classification performance with 93.90% classification accuracy for AD vs. CU and 82.05% for AD vs. MCI on the validation set.

CONCLUSION

The proposed UNB measures were superior to the conventional volume measures in describing the AD-induced cerebral cortex morphological changes. And the UNB-GCN framework combined with attention module may effectively improve the classification performance between MCI subjects and AD patients. Clinical and Translational Impact Statement: This study aims to predict the early AD patients, so as to help clinicians develop effective interventions to delay the deterioration of AD symptoms.

Deep learning-based PET/MR radiomics for the classification of annualized relapse rate in multiple sclerosis

Background Annualized Relapse Rate (ARR) is one of the most important indicators of disease progression in patients with Multiple Sclerosis (MS). However, imaging markers that can effectively predict ARR are currently unavailable. In this study, we developed a deep learning-based method for the automated extraction of radiomics features from Positron Emission Computed Tomography (PET) and Magnetic Resonance (MR) images to predict ARR in patients with MS. Methods Twenty-five patients with a definite diagnosis of Relapsing-Remitting MS (RRMS) were enrolled in this study. We designed a multi-branch fully convolutional neural network to segment lesions from PET/MR images. After that, radiomics features were extracted from the obtained lesion volume of interest. Three feature selection methods were used to retain features highly correlated with ARR. We combined four classifiers with different feature selection methods to form twelve models for ARR classification. Finally, the model with the best performance was chosen. Results Our network achieved precise automatic lesion segmentation with a Dice Similarity Coefficient (DSC) of 0.81 and a precision of 0.86. Radiomics features from lesions filtered by Recursive Feature Elimination (RFE) achieved the best performance in the Support Vector Machines (SVM) classifier. The classification model performance was best when radiomics from both PET and MR were combined to predict ARR, with high accuracy at 0.88 and Area Under the ROC curves (AUC) at 0.96, which outperformed MR or PET-based model and clinical indicators-based model. Conclusion Our automatic segmentation masks can replace manual ones with excellent performance. Furthermore, the deep learning and PET/MR radiomics-based model in our research is an effective tool in assisting ARR classification of MS patients.

[New neuroimaging methods in assessing the activity of neuroinflammation in multiple sclerosis]

The review presents current data on the use of positron emission tomography and single-photon emission computed tomography in multiple sclerosis (MS) to assess the activity of the pathological process, including neuroinflammation, demyelination, activation of microglia, neurodegeneration and local blood flow disorders. These methodologies are a new approach for studying the mechanisms of action and evaluating the clinical effect of disease modifying therapy of MS, especially those capable of penetrating into brain tissue. Among them, the most attention is attracted by cladribine tablets acting on the mechanism of immune reconstitution therapy, most likely with the modulation of immune reactions directly in the brain tissue.

Longitudinal changes in 18F-Flutemetamol amyloid load in cognitively intact APOE4 carriers versus noncarriers: Methodological considerations

PURPOSE

Measuring longitudinal changes in amyloid load in the asymptomatic stage of Alzheimer's disease is of high relevance for clinical research and progress towards more efficacious, timely treatments. Apolipoprotein E ε4 (APOE4) has a well-established effect on the rate of amyloid accumulation. Here we investigated which region of interest and which reference region perform best at detecting the effect of APOE4 on longitudinal amyloid load in individuals participating in the Flemish Prevent Alzheimer's Disease Cohort KU Leuven (F-PACK).

METHODS

Ninety cognitively intact F-PACK participants (baseline age: 68 (52-80) years, 46 males, 42 APOE4 carriers) received structural MRI and ¹⁸F-Flutemetamol PET scans at baseline and follow-up (6.2 (3.4-10.9) year interval). Standardised uptake value ratios (SUVRs) and Centiloids (CLs) were calculated in a composite cortical volume of interest (SUVR_comp/CL) and in the precuneus (SUVR_prec), and amyloid rate of change derived: (follow-up amyloid load - baseline amyloid load) / time interval (years). Four reference regions were used to derive amyloid load: whole cerebellum, cerebellar grey matter, eroded subcortical white matter, and pons.

RESULTS

When using whole cerebellum or cerebellar grey matter as reference region, APOE4 carriers had a significantly higher SUVR_comp amyloid rate of change than non-carriers (p_corr = 0.004, t = 3.40 (CI 0.005-0.018); p_corr = 0.036, t = 2.66 (CI 0.003-0.018), respectively). Significance was not observed for eroded subcortical white matter or pons (p_corr = 0.144, t = 2.13 (CI 0.0003-0.008); p_corr = 0.116, t = 2.22 (CI 0.005-0.010), respectively). When using CLs as the amyloid measurement, and whole cerebellum, APOE4 carriers had a higher amyloid rate of change than non-carriers (p_corr = 0.012, t = 3.05 (CI 0.499-2.359)). Significance was not observed for the other reference regions. No significance was observed with any of the reference regions and amyloid rate of change in the precuneus (SUVR_prec).

CONCLUSION

In this cognitively intact cohort, a composite neocortical volume of interest together with whole cerebellum or cerebellar grey matter as reference region are the methods of choice for detecting APOE4-dependent differences in amyloid rate of change.

Hybrid 18F-florbetapir PET/MRI for assessing myelin recovery in GFAP-A patients

Glial fibrillary acidic protein astrocytopathy (GFAP-A) is a rare autoimmune disease of the central nervous system that was newly reported in 2016. Previous studies have speculated that the pathological mechanism and clinical outcome of GFAP-A lie in the demyelination of the central nervous system, but due to the limitations of MR, this conclusion has not been further confirmed from the perspective of neuroimaging. A non-invasive, quantitative measurement of demyelination would be clinically valuable, given its critical role in mediating GFAP-A. Here, we report a case in which we use ¹⁸F-florbetapir positron emission tomography-magnetic resonance imaging (PET/MRI) to evaluate myelin recovery with follow-up in the patient with GFAP-A. Our patient displayed a decreased uptake of PET tracer ¹⁸F-florbetapir in the brain lesions and lower distribution volume ratio in the damaged white matter lesions compared to the normal-appearing white matter, indicating significant intracranial demyelination. After treatment, the ¹⁸F-florbetapir PET/MRI examination showed a significant increase in the uptake of ¹⁸F-florbetapir in the brain lesions, along with a reduced Expanded Disability Status Scale score. Although only a small number of patients have been validated, this case first reported ¹⁸F-florbetapir PET/MRI could quantitatively and non-invasively assess the myelin recovery in GFAP-A patients, which may lead to improvements in the early diagnosis and long-term prognosis.

Characterization of Radioiodinated Diaryl Oxadiazole Derivatives as SPECT Probes for Detection of Myelin in Multiple Sclerosis

Multiple sclerosis (MS) is an intractable disease of the central nervous system that results from destruction of the myelin sheath. Direct measurement of de- and remyelination is required for monitoring the disease stage of MS, but no useful method has been established. In this study, we characterized four diaryl oxadiazole derivatives as novel myelin-imaging probes for single photon emission computed tomography (SPECT). All the diaryl oxadiazole derivatives penetrated the blood-brain barrier in normal mice. Among them, the highest ratio of radioactivity accumulation in the white matter (myelin-rich region) against the gray matter (myelin-deficient region) was observed at 60 min postinjection of [¹²⁵I]1,3,4-PODP-DM in ex vivo autoradiography using normal mice. In the blocking study with ex vivo autoradiography, the radioactivity accumulation of [¹²⁵I]1,3,4-PODP-DM in the white matter markedly reduced. [¹²⁵I]1,3,4-PODP-DM detected demyelination in the ex vivo autoradiographic images of not only the spinal cord of the experimental autoimmune encephalomyelitis mice but also the brain after lysophosphatidylcholine (LPC) injection. In addition, [¹²³I]1,3,4-PODP-DM could image LPC-induced demyelination in the mouse brain with SPECT. These results suggest that [¹²³I]1,3,4-PODP-DM may be a potential SPECT probe for imaging myelin in MS.

The Role of Molecular Imaging as a Marker of Remyelination and Repair in Multiple Sclerosis

The appearance of new disease-modifying therapies in multiple sclerosis (MS) has revolutionized our ability to fight inflammatory relapses and has immensely improved patients’ quality of life. Although remarkable, this achievement has not carried over into reducing long-term disability. In MS, clinical disability progression can continue relentlessly irrespective of acute inflammation. This “silent” disease progression is the main contributor to long-term clinical disability in MS and results from chronic inflammation, neurodegeneration, and repair failure. Investigating silent disease progression and its underlying mechanisms is a challenge. Standard MRI excels in depicting acute inflammation but lacks the pathophysiological lens required for a more targeted exploration of molecular-based processes. Novel modalities that utilize nuclear magnetic resonance’s ability to display in vivo information on imaging look to bridge this gap. Displaying the CNS through a molecular prism is becoming an undeniable reality. This review will focus on “molecular imaging biomarkers” of disease progression, modalities that can harmoniously depict anatomy and pathophysiology, making them attractive candidates to become the first valid biomarkers of neuroprotection and remyelination.

Positron emission tomography in multiple sclerosis - straight to the target

Following the impressive progress in the treatment of relapsing-remitting multiple sclerosis (MS), the major challenge ahead is the development of treatments to prevent or delay the irreversible accumulation of clinical disability in progressive forms of the disease. The substrate of clinical progression is neuro-axonal degeneration, and a deep understanding of the mechanisms that underlie this process is a precondition for the development of therapies for progressive MS. PET imaging involves the use of radiolabelled compounds that bind to specific cellular and metabolic targets, thereby enabling direct in vivo measurement of several pathological processes. This approach can provide key insights into the clinical relevance of these processes and their chronological sequence during the disease course. In this Review, we focus on the contribution that PET is making to our understanding of extraneuronal and intraneuronal mechanisms that are involved in the pathogenesis of irreversible neuro-axonal damage in MS. We consider the major challenges with the use of PET in MS and the steps necessary to realize clinical benefits of the technique. In addition, we discuss the potential of emerging PET tracers and future applications of existing compounds to facilitate the identification of effective neuroprotective treatments for patients with MS.

Advancements in Positron Emission Tomography/Magnetic Resonance Imaging and Applications to Diagnostic Challenges in Neuroradiology

Since the clinical adoption of magnetic resonance (MR) in medical imaging, MR has proven to be a workhorse in diagnostic neuroradiology, with the ability to provide superb anatomic detail as well as additional functional and physiologic data, depending on the techniques utilized. Positron emission tomography/computed tomography has also shown irreplaceable diagnostic value in certain disease processes of the central nervous system by providing molecular and metabolic information through the development of numerous disease-specific PET tracers, many of which can be utilized as a diagnostic technique in and of themselves or can provide a valuable adjunct to information derived from MR. Despite these advances, many challenges still remain in neuroradiology, particularly in malignancy, neurodegenerative disease, epilepsy, and cerebrovascular disease. Through improvements in attenuation correction, motion correction, and PET detectors, combining the 2 modalities of PET and MR through simultaneous imaging has proven feasible and allows for improved spatial and temporal resolution without compromising either of the 2 individual modalities. The complementary information offered by both technologies has provided increased diagnostic accuracy in both research and many clinical applications in neuroradiology.

18F-florbetapir PET/MRI for quantitatively monitoring myelin loss and recovery in patients with multiple sclerosis: A longitudinal study

BACKGROUND

Amyloid positron emission tomography (PET) can measure in-vivo demyelination in patients with multiple sclerosis (MS). However, the value of 18F-labeled amyloid PET tracer, 18F-florbetapir in the longitudinal study for monitoring myelin loss and recovery has not been confirmed.

METHODS

From March 2019 to September 2020, twenty-three patients with MS and nine healthy controls (HCs) underwent a hybrid PET/MRI at baseline and expanded disability status scale (EDSS) assessment, and eight of 23 patients further underwent follow-up PET/MRI. The distribution volume ratio (DVR) and standard uptake value ratio (SUVR) of 18F-florbetapir in damaged white matter (DWM) and normal-appearance white matter (NAWM) were obtained from dynamic and static PET acquisition. Diffusion tensor imaging-derived parameters were also calculated. Data were expressed as mean ± standard deviation with 99% confidence interval (99%CI).

FINDING

The mean DVR (1.08 ± 0.12, 99%CI [1.02 ~ 1.14]) but not the mean SUVR of DWM lesions was lower than that of NAWM in patients with MS (1.25 ± 0.10, 99%CI [1.20 ~ 1.31]) and HCs (1.29 ± 0.08, 99%CI [1.23 ~ 1.36]). A trend toward lower mean fractional anisotropy (374.95 ± 45.30 vs. 419.07 ± 4.83) and higher mean radial diffusivity (0.45 ± 0.05 vs. 0.40 ± 0.01) of NAWM in patients with MS than those in HCs was found. DVR decreased in DWM lesions with higher MD (rho = -0.261, 99%CI [-0.362 ~ -0.144]), higher AD (rho = -0.200, 99%CI [-0.318 ~ -0.070]) and higher RD (rho = -0.198, 99%CI [-0.313 ~ -0.075]). Patients' EDSS scores were reduced (B = 0.04, 99%CI [-0.005 ~ 0.084]) with decreased index of global demyelination in the longitudinal study.

INTERPRETATION

Our exploratory study suggests that dynamic 18F-florbetapir PET/MRI may be a very promising tool for quantitatively monitoring myelin loss and recovery in patients with MS.

FUNDING

Shanghai Pujiang Program, Shanghai Municipal Key Clinical Specialty, Shanghai Shuguang Plan Project, Shanghai Health and Family Planning Commission Research Project, Clinical Research Plan of SHDC, French-Chinese program "Xu Guangqi".

Metals in Imaging of Alzheimer's Disease

One of the hallmarks of Alzheimer's disease (AD) is the deposition of amyloid plaques in the brain parenchyma, which occurs 7-15 years before the onset of cognitive symptoms of the pathology. Timely diagnostics of amyloid formations allows identifying AD at an early stage and initiating inhibitor therapy, delaying the progression of the disease. However, clinically used radiopharmaceuticals based on 11C and 18F are synchrotron-dependent and short-lived. The design of new metal-containing radiopharmaceuticals for AD visualization is of interest. The development of coordination compounds capable of effectively crossing the blood-brain barrier (BBB) requires careful selection of a ligand moiety, a metal chelating scaffold, and a metal cation, defining the method of supposed Aβ visualization. In this review, we have summarized metal-containing drugs for positron emission tomography (PET), magnetic resonance imaging (MRI), and single-photon emission computed tomography (SPECT) imaging of Alzheimer's disease. The obtained data allow assessing the structure-ability to cross the BBB ratio.

MRI biomarkers of disease progression and conversion to secondary-progressive multiple sclerosis

INTRODUCTION

Conventional imaging measures remain a key clinical tool for the diagnosis multiple sclerosis (MS) and monitoring of patients. However, most measures used in the clinic show unsatisfactory performance in predicting disease progression and conversion to secondary progressive MS.

AREAS COVERED

Sophisticated imaging techniques have facilitated the identification of imaging biomarkers associated with disease progression, such as global and regional brain volume measures, and with conversion to secondary progressive MS, such as leptomeningeal contrast enhancement and chronic inflammation. The relevance of emerging imaging approaches partially overcoming intrinsic limitations of traditional techniques is also discussed.

EXPERT OPINION

Imaging biomarkers capable of detecting tissue damage early on in the disease, with the potential to be applied in multicenter trials and at an individual level in clinical settings, are strongly needed. Several measures have been proposed, which exploit advanced imaging acquisitions and/or incorporate sophisticated post-processing, can quantify irreversible tissue damage. The progressively wider use of high-strength field MRI and the development of more advanced imaging techniques will help capture the missing pieces of the MS puzzle. The ability to more reliably identify those at risk for disability progression will allow for earlier intervention with the aim to favorably alter the disease course.