Demonstration of acute retinal ischemia on diffusion weighted magnetic resonance imaging

Spontaneous brain activity in patients with central retinal artery occlusion: a resting-state functional MRI study using machine learning

Central retinal artery occlusion (CRAO) is a serious eye condition that poses a risk to vision, resulting from the blockage of the central retinal artery. Because of the anatomical connection between the ocular artery, which derives from the internal carotid artery, and the anterior middle cerebral artery, hemodynamic alterations and sudden vision loss associated with CRAO may impact brain functionality. This study aimed to examine alterations in spontaneous neural activity among patients with CRAO by resting-state functional MRI. In addition, we selected the amplitude of low-frequency fluctuation (ALFF) and fractional amplitude of low-frequency fluctuation (fALFF) values as classification features for distinguishing CRAO from healthy controls (HCs) using a support vector machine classifier. A total of 18 patients diagnosed with CRAO and 18 HCs participated in the study. Resting-state brain function images and structural images were acquired from both groups. Aberrant changes in spontaneous brain functional activity among CRAO patients were investigated utilizing ALFF and fALFF analysis methods. Group differences in ALFF/fALFF values were assessed through a two-sample t -test. Subsequently, a machine learning classifier was developed to evaluate the clinical diagnostic potential of ALFF and fALFF values. In comparison to HCs, individuals with CRAO exhibited significantly higher ALFF values in the left cerebellum_6, vermis_7, left superior frontal gyrus, and left inferior frontal gyrus, triangular part. Conversely, the CRAO group displayed notably lower ALFF values in the left precuneus and left median cingulum gyri. Furthermore, higher fALFF values were observed in the left inferior frontal gyrus, triangular part, whereas lower fALFF values were noted in the right cerebellum_Crus2, left precuneus, right angular gyrus, left angular gyrus, right supramarginal gyrus, right superior parietal gyrus, and left precuneus. Utilizing the ALFF/fALFF values, the receiver operating characteristic curves (area under the curve) yielded 0.99 and 0.94 through machine learning analysis techniques. CRAO patients exhibit atypical neural activity in the brain, characterized by ALFF and fALFF values predominantly localized in the frontal, parietal, and cerebellar regions, which are closely linked to visual cognition and motor control impairments. Furthermore, ALFF and fALFF could serve as potential neuroimaging markers beyond the orbit among CRAO.

Unilateral Optic Nerve Diffusion Restriction After Sinus Surgery Secondary to Central Retinal Artery Occlusion: Case Report and Literature Review

INTRODUCTION

Permanent perioperative vision loss is caused by ischemic optic neuropathy (ION) or central retinal artery occlusion (CRAO). Whereas diffusion restriction of the optic nerve (ON) on brain magnetic resonance imaging has been previously reported in perioperative posterior ION (PION), there are no reports of ON diffusion restriction in patients diagnosed with acute perioperative CRAO. We present a case of perioperative CRAO to highlight this neuroimaging finding for neuroradiologists and neurologists.

CASE REPORT

A 71-year-old male without vascular risk factors underwent maxillary bilateral antrostomy and septoplasty for chronic sinusitis. Twenty to thirty minutes upon awakening, he complained of painless left eye vision loss. Ophthalmoscopic examination showed retinal whitening, segmented arterioles, and hyperemic disc. Brain MR-diffusion weighted imaging/apparent diffusion coefficient revealed ON diffusion restriction in the proximal segment. Despite attempted reperfusion, left eye remained with no light perception at 6 months. Patients undergoing nonocular surgeries who develop perioperative vision loss related to PION may exhibit ON diffusion restriction but usually have normal ophthalmoscopic findings. CRAO shows retinal whitening, edema, segmentation of arterioles, and cherry red spot on ophthalmoscopy. A recent study reported that ON diffusion restriction in nonperioperative CRAO cases has a sensitivity and specificity of 55% and 70% to 100%. Here, PION was initially considered based on imaging. However, given the neuro-ophthalmic findings, a proximal embolus in the central retinal artery, obstructing its entrance into the proximal ON was deemed more likely.

CONCLUSION

We highlight that proximal ON diffusion restriction on brain magnetic resonance imaging can be diagnostic of proximal thromboembolic CRAO. Future studies should evaluate the diagnostic utility and accuracy of MR-diffusion weighted imaging/apparent diffusion coefficient in perioperative visual loss.

Retinal and optic nerve magnetic resonance diffusion-weighted imaging in acute non-arteritic central retinal artery occlusion

OBJECTIVES

Diffusion weighted imaging hyperintensity (DWI-H) has been described in the retina and optic nerve during acute central retinal artery occlusion (CRAO). We aimed to determine whether DWI-H can be accurately identified on standard brain magnetic resonance imaging (MRI) in non-arteritic CRAO patients at two tertiary academic centers.

MATERIALS AND METHODS

Retrospective cross-sectional study that included all consecutive adult patients with confirmed acute non-arteritic CRAO and brain MRI performed within 14 days of CRAO. At each center, two neuroradiologists masked to patient clinical data reviewed each MRI for DWI-H in the retina and optic nerve, first independently then together. Statistical analysis for inter-rater reliability and correlation with clinical data was performed.

RESULTS

We included 204 patients [mean age 67.9±14.6 years; 47.5% females; median time from CRAO to MRI 1 day (IQR 1-4.3); 1.5 T in 127/204 (62.3%) and 3.0 T in 77/204 (37.7%)]. Inter-rater reliability varied between centers (κ = 0.27 vs. κ = 0.65) and was better for retinal DWI-H. Miss and error rates significantly differed between neuroradiologists at each center. After consensus review, DWI-H was identified in 87/204 (42.6%) patients [miss rate 117/204 (57.4%) and error rate 11/87 (12.6%)]. Significantly more patients without DWI-H had good visual acuity at follow-up (p = 0.038).

CONCLUSIONS

In this real-world case series, differences in agreement and interpretation accuracy among neuroradiologists limited the role of DWI-H in diagnosing acute CRAO on standard MRI. DWI-H was identified in 42.6% of patients and was more accurately detected in the retina than in the optic nerve. Further studies are needed with standardized novel MRI protocols.

Advanced Diffusion MRI of the Visual System in Glaucoma: From Experimental Animal Models to Humans

Simple Summary

This review summarizes current applications of advanced diffusion magnetic resonance imaging (MRI) throughout the glaucomatous visual system, focusing on the eye, optic nerve, optic tract, subcortical visual brain nuclei, optic radiations, and visual cortex. Glaucoma continues to be the leading cause of irreversible blindness worldwide and often remains undetected until later disease stages. The development of non-invasive methods for early detection of visual pathway integrity could pave the way for timely intervention and targeted treatment strategies. Principles of diffusion have been integrated with MRI protocols to produce a diffusion-weighted imaging modality for studying changes to tissue microstructures by quantifying the movement of water molecules in vivo. The development and applications of diffusion MRI in ophthalmology have allowed a better understanding of neural pathway changes in glaucoma. The feasibility of translating diffusion MRI techniques to assess both humans and experimental animal models of glaucoma and other optic neuropathies or neurodegenerative diseases is discussed. Recent research focuses on overcoming limitations in imaging quality, acquisition times, and biological interpretation suggest that diffusion MRI can provide an important tool for the non-invasive evaluation of glaucomatous changes in the visual system.

Abstract

Glaucoma is a group of ophthalmologic conditions characterized by progressive retinal ganglion cell death, optic nerve degeneration, and irreversible vision loss. While intraocular pressure is the only clinically modifiable risk factor, glaucoma may continue to progress at controlled intraocular pressure, indicating other major factors in contributing to the disease mechanisms. Recent studies demonstrated the feasibility of advanced diffusion magnetic resonance imaging (dMRI) in visualizing the microstructural integrity of the visual system, opening new possibilities for non-invasive characterization of glaucomatous brain changes for guiding earlier and targeted intervention besides intraocular pressure lowering. In this review, we discuss dMRI methods currently used in visual system investigations, focusing on the eye, optic nerve, optic tract, subcortical visual brain nuclei, optic radiations, and visual cortex. We evaluate how conventional diffusion tensor imaging, higher-order diffusion kurtosis imaging, and other extended dMRI techniques can assess the neuronal and glial integrity of the visual system in both humans and experimental animal models of glaucoma, among other optic neuropathies or neurodegenerative diseases. We also compare the pros and cons of these methods against other imaging modalities. A growing body of dMRI research indicates that this modality holds promise in characterizing early glaucomatous changes in the visual system, determining the disease severity, and identifying potential neurotherapeutic targets, offering more options to slow glaucoma progression and to reduce the prevalence of this world’s leading cause of irreversible but preventable blindness.

Detectability of Retinal Diffusion Restriction in Central Retinal Artery Occlusion is Linked to Inner Retinal Layer Thickness

PURPOSE

To investigate retinal microstructure differences in central retinal artery occlusion (CRAO) patients with and without visible retinal diffusion restriction (RDR) on diffusion-weighted magnetic resonance imaging (DWI).

METHODS

Consecutive CRAO patients with available optical coherence tomography (OCT) and DWI, both performed within 7 days after symptom onset, were included in a retrospective cohort study. The OCT scans were reviewed to assess retinal layer thickness, optical intensity and structural integrity. The OCT findings were compared between patients with and without visible RDR on DWI using Mann-Whitney U or Pearson's Χ² test.

RESULTS

A total of 56 patients (mean age 70.8 ± 12.8 years) were included. RDR was observed in 38 subjects (67.9%) with visually correlating low ADC map in 26 of 38 cases (68.4%). Superior and inferior parafoveal macular thickness measurements (SMT, IMT) of RDR negative patients were significantly lower when compared to RDR+ patients (370.5 ± 43.8 µm vs. 418.2 ± 76.0 µm, p = 0.016; 374.4 ± 42.9 µm vs. 428.8 ± 63.2 µm, p = 0.004) due to differences in inner retinal layer thickness (IRLT, 188.8 ± 34.4 µm vs. 234.7 ± 49.0 µm, p = 0.002). IRLT values of RDR negative patients were higher in 1.5T compared to 3T the DWI (205.0 ± 26.0 µm vs. 168.6 ± 32.8 µm, p = 0.026).

CONCLUSIONS

Detectability of RDR is likely contingent upon the degree of ischemic retinal swelling in CRAO. Technical adjustments to the DWI protocol, such as increased field strength, may improve visibility of RDR.

Retinal diffusion restrictions in acute branch retinal arteriolar occlusion

This study sought to investigate the occurrence of retinal diffusion restrictions (RDR) in branch retinal arteriolar occlusion (BRAO) using standard brain diffusion-weighted imaging (DWI). Two radiologists assessed DWI MRI scans of BRAO patients for RDR in a retrospective cohort study. Inter- and intrarater reliability were calculated using Kappa statistics. Detection rates of RDR were compared among MRI scans with varying field strength, sequence type and onset-to-DWI time intervals. 85 BRAO patients (63.1 ± 16.5 years) and 89 DWI scans were evaluated. Overall sensitivity of RDR in BRAO was 46.1% with visually correlating low ADC signal in 56.1% of cases. Localization of RDR matched distribution of fundoscopic retinal edema in 85% of patients. Inter- and intra-rater agreement for RDR in BRAO was κ_inter = 0.64 (95% CI 0.48–0.80) and κ_intra = 0.87 (95% CI 0.76–0.96), respectively. RDR detection rate tended to be higher for 3T, when compared to 1.5T MRI scans (53.7% vs. 34.3%%; p = 0.07). RDR were identified within 24 h up to 2 weeks after onset of visual impairment. RDR in BRAO can be observed by means of standard stroke DWI in a substantial proportion of cases, although sensitivity and interrater reliability were lower than previously reported for complete central retinal artery occlusion.

Time Course and Clinical Correlates of Retinal Diffusion Restrictions in Acute Central Retinal Artery Occlusion

BACKGROUND AND PURPOSE

Retinal diffusion restrictions were recently identified as a regular finding in acute central retinal artery occlusion. We sought to investigate the influence of technical MR imaging and clinical parameters on the detection rate of retinal diffusion restrictions on standard brain DWI.

MATERIALS AND METHODS

In this retrospective cohort study, MR imaging scans of patients with central retinal artery occlusion were assessed by 2 readers for retinal diffusion restrictions on DWI performed within 2 weeks after vision loss. The influence of clinical and technical MR imaging parameters and the time interval between symptom onset and DWI on the presence of retinal diffusion restrictions were evaluated.

RESULTS

One hundred twenty-seven patients (mean age, 69.6 [SD 13.9] years; 59 women) and 131 DWI scans were included. Overall, the MR imaging sensitivity of retinal diffusion restrictions in acute central retinal artery occlusion was 62.6%-67.2%. Interrater and intrarater agreement for retinal diffusion restrictions was "substantial" with κ_inter= 0.70 (95% CI, 0.57-0.83) and κ_intra= 0.75 (95% CI, 0.63-0.88). Detection of retinal diffusion restrictions did not differ with differences in field strengths (1.5 versus 3T, P = .35) or sequence type (P = .22). Retinal diffusion restrictions were consistently identified within the first week with a peak sensitivity of 79% in DWI performed within 24 hours after symptom onset. Sensitivity of retinal diffusion restrictions declined in the second week (10.0%, P < .001). Absence of retinal diffusion restrictions was more prevalent in patients without fundoscopic retinal edema (60% versus 27.1%, P = .004) and with restitution of visual acuity at discharge (75% versus 28.4%, P = .006).

CONCLUSIONS

Retinal diffusion restrictions in acute central retinal artery occlusion can be reliably identified on DWI performed within 24 hours and 1 week after onset of visual impairment. Detectability of retinal diffusion restrictions is dependent on the clinical course of the disease.

Study to elucidate the pharmacological activity of retinalamin in a rat model of ischemic retinopathy

Introduction: Over the past few years, the incidence of retinal ischemic disorders has been increasing, due to a rising prevalence of such socially burdensome diseases as diabetes and hypertension, which ultimately lead to ocular vascular pathology. The identification of new treatment options that would prevent retinal neuron death is a crucial task of modern pharmacology.

Materials and methods: The research was carried out on male Wistar rats. Retinopathy was modeled by inducing a 30-min ischemic episode, with a 72-hour period of reperfusion and subsequent administration of Retinalamin and Emoxypine for 10 days. The effectiveness of the drugs was evaluated by electroretinographic, ophthalmoscopic and morphological assessments.

Results and discussion: On Day 14 of the experiment, a dose-dependent preservation of the electroretinogram b-wave/a-wave amplitude ratio was observed in the animals treated with Retinalamin depending on a dose (1.39±0.06, 1.46±0.03 and 1.49±0.04 in low (0.214 mg/kg), medium (0.428 mg/kg) and high (0.857 mg/kg) Retinalamin dose groups, respectively). The ophthalmoscopic picture of the fundus oculi also improved following the treatment with Retinalamin (1.42, 1.69 and 1.90 times lower ophthalmoscopic scores compared to placebo-treated animals in low, medium and high dose groups, respectively). The morphologic “coefficient of change” applied to ganglion cell layer was 2.2, 1.7 and 1.6 points in low, medium and high dose Retinalamin groups, respectively. These results are significantly different from both intact and placebo group (p&lt;0.05). Based on the aforementioned experimental findings, we conclude that Retinalamin has a retinoprotective effect and is superior to the drug of comparison (Emoxypine).

Conclusion: The greatest neuroprotective effects were shown in the groups receiving Retinalamin. In these groups, the ERG b-wave/a-wave amplitude ratio was preserved, the ophthalmoscopic picture was less pathologic and retinal morphology features were close to those of the intact retina.

Standard Diffusion-weighted MRI for the Diagnosis of Central Retinal Artery Occlusion

Purpose

To evaluate diffusion abnormalities of the retina and optic nerve in patients with central retinal artery occlusion (CRAO) using standard stroke diffusion-weighted magnetic resonance imaging (DWI).

Methods

In this case-control study, DWI scans of patients with nonarteritic CRAO were retrospectively assessed for acute ischemia of the retina and optic nerve. Two neuroradiologists, blinded for patient diagnosis, randomly evaluated DWI of CRAO patients and controls (a collective of stroke and transient ischemic attack [TIA] patients) for restrictions of the retina and optic nerve. We calculated statistical quality criteria and analyzed inter-rater reliability using unweighted Kappa statistics.

Results

20 CRAO patients (60,6 ± 17 years) and 20 controls (60,7 ± 17 years) were included in the study. Sensitivity, specificity, positive and negative predictive values for retinal DWI restrictions were 75%/80%/79%/76% (reader 1) and 75%/100%/100%/80% (reader 2), respectively. Unweighted Kappa was κ = 0,70 (95% CI 0,48‑0,92), indicating “substantial” interrater reliability. In comparison, sensitivity, specificity, PPV and NPV (positive and negative predictive values) for restrictions of the optic nerve in CRAO were 55%/70%/65%/61% (reader 1) and 25%/100%/100%/57% (reader 2). Inter-rater reliability was “fair” with unweighted Kappa κ = 0,32 (95% CI 0,09‑0,56).

Conclusions

Retinal diffusion restrictions were present in a majority of CRAO patients and detectable with reasonable sensitivity, high specificity and substantial inter-rater reliability. Further studies are necessary to study time dependency of retinal diffusion restrictions, improve image quality and investigate the reliability of retinal DWI to discern CRAO from other causes of acute loss of vision.

Electronic supplementary material

The online version of this article (10.1007/s00062-020-00955-6) contains supplementary material, which is available to authorized users.