Double diffusion encoding and applications for biomedical imaging

Novel pore size-controlled, susceptibility matched, 3D-printed MRI phantoms

PURPOSE

We report the design concept and fabrication of MRI phantoms, containing blocks of aligned microcapillaires that can be stacked into larger arrays to construct diameter distribution phantoms or fractured, to create a "powder-averaged" emulsion of randomly oriented blocks for vetting or calibrating advanced MRI methods, that is, diffusion tensor imaging, AxCaliber MRI, MAP-MRI, and multiple pulsed field gradient or double diffusion-encoded microstructure imaging methods. The goal was to create a susceptibility-matched microscopically anisotropic but macroscopically isotropic phantom with a ground truth diameter that could be used to vet advanced diffusion methods for diameter determination in fibrous tissues.

METHODS

Two-photon polymerization, a novel three-dimensional printing method is used to fabricate blocks of capillaries. Double diffusion encoding methods were employed and analyzed to estimate the expected MRI diameter.

RESULTS

Susceptibility-matched microcapillary blocks or modules that can be assembled into large-scale MRI phantoms have been fabricated and measured using advanced diffusion methods, resulting in microscopic anisotropy and random orientation.

CONCLUSION

This phantom can vet and calibrate various advanced MRI methods and multiple pulsed field gradient or diffusion-encoded microstructure imaging methods. We demonstrated that two double diffusion encoding methods underestimated the ground truth diameter.

Diffusion-weighted MR spectroscopy: Consensus, recommendations, and resources from acquisition to modeling

Brain cell structure and function reflect neurodevelopment, plasticity, and aging; and changes can help flag pathological processes such as neurodegeneration and neuroinflammation. Accurate and quantitative methods to noninvasively disentangle cellular structural features are needed and are a substantial focus of brain research. Diffusion-weighted MRS (dMRS) gives access to diffusion properties of endogenous intracellular brain metabolites that are preferentially located inside specific brain cell populations. Despite its great potential, dMRS remains a challenging technique on all levels: from the data acquisition to the analysis, quantification, modeling, and interpretation of results. These challenges were the motivation behind the organization of the Lorentz Center workshop on "Best Practices & Tools for Diffusion MR Spectroscopy" held in Leiden, the Netherlands, in September 2021. During the workshop, the dMRS community established a set of recommendations to execute robust dMRS studies. This paper provides a description of the steps needed for acquiring, processing, fitting, and modeling dMRS data, and provides links to useful resources.

Compensation of concomitant field effects in double diffusion encoding by means of added oscillating gradients

Maxwell or concomitant fields imprint additional phases on the transverse magnetization. This concomitant phase may cause severe image artifacts like signal voids or distort the quantitative parameters due to the induced intravoxel dephasing. In particular, double diffusion encoding (DDE) schemes with two pairs of bipolar diffusion-weighting gradients separated by a refocusing radiofrequency (RF) pulse are prone to concomitant field-induced artifacts. In this work, a method for reducing concomitant field effects in these DDE sequences based on additional oscillating gradients is presented. These oscillating gradient pulses obtained by constrained optimization were added to the original gradient waveforms. The modified sequences reduced the accumulated concomitant phase without significant changes in the original sequence characteristics. The proposed method was applied to a DDE acquisition scheme consisting of 60 pairs of diffusion wave vectors. For phantom as well as for in vivo experiments, a considerable increase in the signal-to-noise ratio (SNR) was obtained. For phantom measurements with a diffusion weighting of b = 2000 s/mm2 for each of the gradient pairs, an SNR increase of up to 40% was observed for a transversal slice that had a distance of 5 cm from the isocenter. For equivalent slice parameters, in vivo measurements in the brain of a healthy volunteer exhibited an increase in SNR of up to 35% for b = 750 s/mm2 for each weighting. These findings are supported by corresponding simulations, which also predict a positive effect on the SNR. In summary, the presented method leads to an SNR gain without additional RF refocusing pulses.

Linear multi-scale modeling of diffusion MRI data: A framework for characterization of oriented structures across length scales

Diffusion-weighted magnetic resonance imaging (DW-MRI) has evolved to provide increasingly sophisticated investigations of the human brain's structural connectome in vivo. Restriction spectrum imaging (RSI) is a method that reconstructs the orientation distribution of diffusion within tissues over a range of length scales. In its original formulation, RSI represented the signal as consisting of a spectrum of Gaussian diffusion response functions. Recent technological advances have enabled the use of ultra-high b-values on human MRI scanners, providing higher sensitivity to intracellular water diffusion in the living human brain. To capture the complex diffusion time dependence of the signal within restricted water compartments, we expand upon the RSI approach to represent restricted water compartments with non-Gaussian response functions, in an extended analysis framework called linear multi-scale modeling (LMM). The LMM approach is designed to resolve length scale and orientation-specific information with greater specificity to tissue microstructure in the restricted and hindered compartments, while retaining the advantages of the RSI approach in its implementation as a linear inverse problem. Using multi-shell, multi-diffusion time DW-MRI data acquired with a state-of-the-art 3 T MRI scanner equipped with 300 mT/m gradients, we demonstrate the ability of the LMM approach to distinguish different anatomical structures in the human brain and the potential to advance mapping of the human connectome through joint estimation of the fiber orientation distributions and compartment size characteristics.

A review on investigation of the basic contrast mechanism underlying multidimensional diffusion MRI in assessment of neurological disorders

INTRODUCTION

Multidimensional diffusion MRI (MDD MRI) is a novel diffusion technique that uses advanced gradient waveforms for microstructural tissue characterization to provide information about average rate, anisotropy and orientation of the diffusion and to disentangle the signal fraction from specific cell types i.e., elongated cells, isotropic cells and free water.

AIM

To review the diagnostic potential of MDD MRI in the clinical setting for microstructural tissue characterization in patients with neurological disorders to aid in patient care and treatment.

METHOD

A scoping review on the clinical applications of MDD MRI was conducted from original articles published in PubMed and Scopus from 2015 to 2021 using the keywords "Multidimensional diffusion MRI" OR "diffusion tensor distribution" OR "Tensor-Valued Diffusion" OR "b-tensor encoding" OR "microscopic diffusion anisotropy" OR "microscopic anisotropy" OR "microscopic fractional anisotropy" OR "double diffusion encoding" OR "triple diffusion encoding" OR "double pulsed field gradients" OR "double wave vector" OR "correlation tensor imaging" AND "brain" OR "axons".

RESULTS

Initially 145 articles were screened and after applying inclusion and exclusion criteria, nine articles were included in the final analysis. In most of these studies, microscopic diffusion anisotropy within the lesion showed deviation from the normal-appearing tissue.

CONCLUSION

Multidimensional diffusion MRI can provide better quantification and visualization of tissue microstructure than conventional diffusion MRI and can be used in the clinical setting for diagnosis of neurological disorders.

Separating Glioma Hyperintensities From White Matter by Diffusion-Weighted Imaging With Spherical Tensor Encoding

Background

Tumor-related hyperintensities in high b-value diffusion-weighted imaging (DWI) are radiologically important in the workup of gliomas. However, the white matter may also appear as hyperintense, which may conflate interpretation.

Purpose

To investigate whether DWI with spherical b-tensor encoding (STE) can be used to suppress white matter and enhance the conspicuity of glioma hyperintensities unrelated to white matter.

Materials and Methods

Twenty-five patients with a glioma tumor and at least one pathology-related hyperintensity on DWI underwent conventional MRI at 3 T. The DWI was performed both with linear and spherical tensor encoding (LTE-DWI and STE-DWI). The LTE-DWI here refers to the DWI obtained with conventional diffusion encoding and averaged across diffusion-encoding directions. Retrospectively, the differences in contrast between LTE-DWI and STE-DWI, obtained at a b-value of 2,000 s/mm², were evaluated by comparing hyperintensities and contralateral normal-appearing white matter (NAWM) both visually and quantitatively in terms of the signal intensity ratio (SIR) and contrast-to-noise ratio efficiency (CNR_eff).

Results

The spherical tensor encoding DWI was more effective than LTE-DWI at suppressing signals from white matter and improved conspicuity of pathology-related hyperintensities. The median SIR improved in all cases and on average by 28%. The median (interquartile range) SIR was 1.9 (1.6 – 2.1) for STE and 1.4 (1.3 – 1.7) for LTE, with a significant difference of 0.4 (0.3 –0.5) (p < 10^–4, paired U-test). In 40% of the patients, the SIR was above 2 for STE-DWI, but with LTE-DWI, the SIR was below 2 for all patients. The CNR_eff of STE-DWI was significantly higher than of LTE-DWI: 2.5 (2 – 3.5) vs. 2.3 (1.7 – 3.1), with a significant difference of 0.4 (−0.1 –0.6) (p < 10^–3, paired U-test). The STE improved CNR_eff in 70% of the cases. We illustrate the benefits of STE-DWI in three patients, where STE-DWI may facilitate an improved radiological description of tumor-related hyperintensity, including one case that could have been missed out if only LTE-DWI was inspected.

Conclusion

The contrast mechanism of high b-value STE-DWI results in a stronger suppression of white matter than conventional LTE-DWI, and may, therefore, be more sensitive and specific for assessment of glioma tumors and DWI-hyperintensities.

In vivo Correlation Tensor MRI reveals microscopic kurtosis in the human brain on a clinical 3T scanner

Diffusion MRI (dMRI) has become one of the most important imaging modalities for noninvasively probing tissue microstructure. Diffusional Kurtosis MRI (DKI) quantifies the degree of non-gaussian diffusion, which in turn has been shown to increase sensitivity towards, e.g., disease and orientation mapping in neural tissue. However, the specificity of DKI is limited as different sources can contribute to the total intravoxel diffusional kurtosis, including: variance in diffusion tensor magnitudes (K_iso), variance due to diffusion anisotropy (K_aniso), and microscopic kurtosis (μK) related to restricted diffusion, microstructural disorder, and/or exchange. Interestingly, μK is typically ignored in diffusion MRI signal modeling as it is assumed to be negligible in neural tissues. However, recently, Correlation Tensor MRI (CTI) based on Double-Diffusion-Encoding (DDE) was introduced for kurtosis source separation, revealing non negligible μK in preclinical imaging. Here, we implemented CTI for the first time on a clinical 3T scanner and investigated the sources of total kurtosis in healthy subjects. A robust framework for kurtosis source separation in humans is introduced, followed by estimation of μK (and the other kurtosis sources) in the healthy brain. Using this clinical CTI approach, we find that μK significantly contributes to total diffusional kurtosis both in gray and white matter tissue but, as expected, not in the ventricles. The first μK maps of the human brain are presented, revealing that the spatial distribution of μK provides a unique source of contrast, appearing different from isotropic and anisotropic kurtosis counterparts. Moreover, group average templates of these kurtosis sources have been generated for the first time, which corroborated our findings at the underlying individual-level maps. We further show that the common practice of ignoring μK and assuming the multiple gaussian component approximation for kurtosis source estimation introduces significant bias in the estimation of other kurtosis sources and, perhaps even worse, compromises their interpretation. Finally, a twofold acceleration of CTI is discussed in the context of potential future clinical applications. We conclude that CTI has much potential for future in vivo microstructural characterizations in healthy and pathological tissue.

Mapping the Human Connectome using Diffusion MRI at 300 mT/m Gradient Strength: Methodological Advances and Scientific Impact

Tremendous efforts have been made in the last decade to advance cutting-edge MRI technology in pursuit of mapping structural connectivity in the living human brain with unprecedented sensitivity and speed. The first Connectom 3T MRI scanner equipped with a 300 mT/m whole-body gradient system was installed at the Massachusetts General Hospital in 2011 and was specifically constructed as part of the Human Connectome Project. Since that time, numerous technological advances have been made to enable the broader use of the Connectom high gradient system for diffusion tractography and tissue microstructure studies and leverage its unique advantages and sensitivity to resolving macroscopic and microscopic structural information in neural tissue for clinical and neuroscientific studies. The goal of this review article is to summarize the technical developments that have emerged in the last decade to support and promote large-scale and scientific studies of the human brain using the Connectom scanner. We provide a brief historical perspective on the development of Connectom gradient technology and the efforts that led to the installation of three other Connectom 3T MRI scanners worldwide - one in the United Kingdom in Cardiff, Wales, another in Continental Europe in Leipzig, Germany, and the latest in Asia in Shanghai, China. We summarize the key developments in gradient hardware and image acquisition technology that have formed the backbone of Connectom-related research efforts, including the rich array of high-sensitivity receiver coils, pulse sequences, image artifact correction strategies and data preprocessing methods needed to optimize the quality of high-gradient strength dMRI data for subsequent analyses. Finally, we review the scientific impact of the Connectom MRI scanner, including advances in diffusion tractography, tissue microstructural imaging, ex vivo validation, and clinical investigations that have been enabled by Connectom technology. We conclude with brief insights into the unique value of strong gradients for dMRI and where the field is headed in the coming years.

Accelerating joint relaxation-diffusion MRI by integrating time division multiplexing and simultaneous multi-slice (TDM-SMS) strategies

PURPOSE

To accelerate the acquisition of relaxation-diffusion imaging by integrating time-division multiplexing (TDM) with simultaneous multi-slice (SMS) for EPI and evaluate imaging quality and diffusion measures.

METHODS

The time-division multiplexing (TDM) technique and SMS method were integrated to achieve a high slice-acceleration (e.g., 6×) factor for acquiring relaxation-diffusion MRI. Two variants of the sequence, referred to as TDM3e-SMS and TDM2s-SMS, were developed to simultaneously acquire slice groups with three distinct TEs and two slice groups with the same TE, respectively. Both sequences were evaluated on a 3T scanner with in vivo human brains and compared with standard single-band (SB) -EPI and SMS-EPI using diffusion measures and tractography results.

RESULTS

Experimental results showed that the TDM3e-SMS sequence with total slice acceleration of 6 (multiplexing factor (MP) = 3 × multi-band factor (MB) = 2) provided similar image intensity and microstructure measures compared to standard SMS-EPI with MB = 2, and yielded less bias in intensity compared to standard SMS-EPI with MB = 4. The three sequences showed a similar positive correlation between TE and mean kurtosis (MK) and a negative correlation between TE and mean diffusivity (MD) in white matter. Multi-fiber tractography also shows consistency of results in TE-dependent measures between different sequences. The TDM2s-SMS sequence (MP = 2, MB = 2) also provided imaging measures similar to standard SMS-EPI sequences (MB = 2) for single-TE diffusion imaging.

CONCLUSIONS

The TDM-SMS sequence can provide additional 2× to 3× acceleration to SMS without degrading imaging quality. With the significant reduction in scan time, TDM-SMS makes joint relaxation-diffusion MRI a feasible technique in neuroimaging research to investigate new markers of brain disorders.

Connectome 2.0: Developing the next-generation ultra-high gradient strength human MRI scanner for bridging studies of the micro-, meso- and macro-connectome

The first phase of the Human Connectome Project pioneered advances in MRI technology for mapping the macroscopic structural connections of the living human brain through the engineering of a whole-body human MRI scanner equipped with maximum gradient strength of 300 mT/m, the highest ever achieved for human imaging. While this instrument has made important contributions to the understanding of macroscale connectional topology, it has also demonstrated the potential of dedicated high-gradient performance scanners to provide unparalleled in vivo assessment of neural tissue microstructure. Building on the initial groundwork laid by the original Connectome scanner, we have now embarked on an international, multi-site effort to build the next-generation human 3T Connectome scanner (Connectome 2.0) optimized for the study of neural tissue microstructure and connectional anatomy across multiple length scales. In order to maximize the resolution of this in vivo microscope for studies of the living human brain, we will push the diffusion resolution limit to unprecedented levels by (1) nearly doubling the current maximum gradient strength from 300 mT/m to 500 mT/m and tripling the maximum slew rate from 200 T/m/s to 600 T/m/s through the design of a one-of-a-kind head gradient coil optimized to minimize peripheral nerve stimulation; (2) developing high-sensitivity multi-channel radiofrequency receive coils for in vivo and ex vivo human brain imaging; (3) incorporating dynamic field monitoring to minimize image distortions and artifacts; (4) developing new pulse sequences to integrate the strongest diffusion encoding and highest spatial resolution ever achieved in the living human brain; and (5) calibrating the measurements obtained from this next-generation instrument through systematic validation of diffusion microstructural metrics in high-fidelity phantoms and ex vivo brain tissue at progressively finer scales with accompanying diffusion simulations in histology-based micro-geometries. We envision creating the ultimate diffusion MRI instrument capable of capturing the complex multi-scale organization of the living human brain - from the microscopic scale needed to probe cellular geometry, heterogeneity and plasticity, to the mesoscopic scale for quantifying the distinctions in cortical structure and connectivity that define cyto- and myeloarchitectonic boundaries, to improvements in estimates of macroscopic connectivity.

Evidence for microscopic kurtosis in neural tissue revealed by correlation tensor MRI

PURPOSE

The impact of microscopic diffusional kurtosis (µK), arising from restricted diffusion and/or structural disorder, remains a controversial issue in contemporary diffusion MRI (dMRI). Recently, correlation tensor imaging (CTI) was introduced to disentangle the sources contributing to diffusional kurtosis, without relying on a-priori multi-gaussian component (MGC) or other microstructural assumptions. Here, we investigated µK in in vivo rat brains and assessed its impact on state-of-the-art methods ignoring µK.

THEORY AND METHODS

CTI harnesses double diffusion encoding (DDE) experiments, which were here improved for speed and minimal bias using four different sets of acquisition parameters. The robustness of the improved CTI protocol was assessed via simulations. In vivo CTI acquisitions were performed in healthy rat brains using a 9.4T pre-clinical scanner equipped with a cryogenic coil, and targeted the estimation of µK, anisotropic kurtosis, and isotropic kurtosis.

RESULTS

The improved CTI acquisition scheme substantially reduces scan time and importantly, also minimizes higher-order-term biases, thus enabling robust µK estimation, alongside K_aniso and K_iso metrics. Our CTI experiments revealed positive µK both in white and gray matter of the rat brain in vivo; µK is the dominant kurtosis source in healthy gray matter tissue. The non-negligible µK substantially were found to bias prior MGC analyses of K_iso and K_aniso .

CONCLUSIONS

Correlation Tensor MRI offers a more accurate and robust characterization of kurtosis sources than its predecessors. µK is non-negligible in vivo in healthy white and gray matter tissues and could be an important biomarker for future studies. Our findings thus have both theoretical and practical implications for future dMRI research.

Diffusional Kurtosis Imaging in the Diffusion Imaging in Python Project

Diffusion-weighted magnetic resonance imaging (dMRI) measurements and models provide information about brain connectivity and are sensitive to the physical properties of tissue microstructure. Diffusional Kurtosis Imaging (DKI) quantifies the degree of non-Gaussian diffusion in biological tissue from dMRI. These estimates are of interest because they were shown to be more sensitive to microstructural alterations in health and diseases than measures based on the total anisotropy of diffusion which are highly confounded by tissue dispersion and fiber crossings. In this work, we implemented DKI in the Diffusion in Python (DIPY) project-a large collaborative open-source project which aims to provide well-tested, well-documented and comprehensive implementation of different dMRI techniques. We demonstrate the functionality of our methods in numerical simulations with known ground truth parameters and in openly available datasets. A particular strength of our DKI implementations is that it pursues several extensions of the model that connect it explicitly with microstructural models and the reconstruction of 3D white matter fiber bundles (tractography). For instance, our implementations include DKI-based microstructural models that allow the estimation of biophysical parameters, such as axonal water fraction. Moreover, we illustrate how DKI provides more general characterization of non-Gaussian diffusion compatible with complex white matter fiber architectures and gray matter, and we include a novel mean kurtosis index that is invariant to the confounding effects due to tissue dispersion. In summary, DKI in DIPY provides a well-tested, well-documented and comprehensive reference implementation for DKI. It provides a platform for wider use of DKI in research on brain disorders and in cognitive neuroscience.

Accelerated diffusion and relaxation-diffusion MRI using time-division multiplexing EPI

PURPOSE

To develop a time-division multiplexing echo-planar imaging (TDM-EPI) sequence for approximately two- to threefold acceleration when acquiring joint relaxation-diffusion MRI data with multiple TEs.

METHODS

The proposed TDM-EPI sequence interleaves excitation and data collection for up to 3 separate slices at different TEs and uses echo-shifting gradients to disentangle the overlapping echo signals during the readout period. By properly arranging the sequence event blocks for each slice and adjusting the echo-shifting gradients, diffusion-weighted images from separate slices can be acquired. Therefore, we present 2 variants of the sequence. A single-TE TDM-EPI is presented to demonstrate the concept. Next, a multi-TE TDM-EPI is presented to highlight the advantages of the TDM approach for relaxation-diffusion imaging. These sequences were evaluated on a 3 Tesla scanner with a water phantom and in vivo human brain data.

RESULTS

The single-TE TDM-EPI sequence can simultaneously acquire 2 slices with a maximum b value of 3000 s/mm² and 2.5 mm isotropic resolution using interleaved readout windows with TE ≈ 78 ms. With the same b value and resolution, the multi-TE TDM-EPI sequence can simultaneously acquire 2 or 3 separate slices using interleaved readout sections with shortest TE ≈ 70 ms and ΔTE ≈ 30 ms. Phantom and in vivo experiments have shown that the proposed TDM-EPI sequences can provide similar image quality and diffusion measures as conventional EPI readouts with multiple echoes but can reduce the overall relaxation-diffusion protocol scan time by approximately two- to threefold.

CONCLUSION

TDM-EPI is a novel approach to acquire diffusion imaging data at multiple TEs. This enables a significant reduction in acquisition time for relaxation-diffusion MRI experiments but without compromising image quality and diffusion measurements, thus removing a significant barrier to the adoption of relaxation-diffusion MRI in clinical research studies of neurological and mental disorders.

Compartmental diffusion and microstructural properties of human brain gray and white matter studied with double diffusion encoding magnetic resonance spectroscopy of metabolites and water

Double diffusion encoding (DDE) of the water signal offers a unique ability to separate the effect of microscopic anisotropic diffusion in structural units of tissue from the overall macroscopic orientational distribution of cells. However, the specificity in detected microscopic anisotropy is limited as the signal is averaged over different cell types and across tissue compartments. Performing side-by-side water and metabolite DDE spectroscopic (DDES) experiments provides complementary measures from which intracellular and extracellular microscopic fractional anisotropies (μFA) and diffusivities can be estimated. Metabolites are largely confined to the intracellular space and therefore provide a benchmark for intracellular μFA and diffusivities of specific cell types. By contrast, water DDES measurements allow examination of the separate contributions to water μFA and diffusivity from the intra- and extracellular spaces, by using a wide range of b values to gradually eliminate the extracellular contribution. Here, we aimed to estimate tissue and compartment specific human brain microstructure by combining water and metabolites DDES experiments. We performed our DDES measurements in two brain regions that contain widely different amounts of white matter (WM) and gray matter (GM): parietal white matter (PWM) and occipital gray matter (OGM) in a total of 20 healthy volunteers at 7 Tesla. Metabolite DDES measurements were performed at b = 7199 s/mm², while water DDES measurements were performed with a range of b values from 918 to 7199 s/mm². The experimental framework we employed here resulted in a set of insights pertaining to the morphology of the intracellular and extracellular spaces in both gray and white matter. Results of the metabolite DDES experiments in both PWM and OGM suggest a highly anisotropic intracellular space within neurons and glia, with the possible exception of gray matter glia. The water μFA obtained from the DDES results at high b values in both regions converged with that of the metabolite DDES, suggesting that the signal from the extracellular space is indeed effectively suppressed at the highest b value. The μFA measured in the OGM significantly decreased at lower b values, suggesting a considerably lower anisotropy of the extracellular space in GM compared to WM. In PWM, the water μFA remained high even at the lowest b value, indicating a high degree of organization in the interstitial space in WM. Tortuosity values in the cytoplasm for water and tNAA, obtained with correlation analysis of microscopic parallel diffusivity with respect to GM/WM tissue fraction in the volume of interest, are remarkably similar for both molecules, while exhibiting a clear difference between gray and white matter, suggesting a more crowded cytoplasm and more complex cytomorphology of neuronal cell bodies and dendrites in GM than those found in long-range axons in WM.

The present and the future of microstructure MRI: From a paradigm shift to normal science

The aspiration of imaging tissue microstructure with MRI is to uncover micrometer-scale tissue features within millimeter-scale imaging voxels, in vivo. This kind of super-resolution has fueled a paradigm shift within the biomedical imaging community. However, what feels like an ongoing revolution in MRI, has been conceptually experienced in physics decades ago; from this point of view, our current developments can be seen as Thomas Kuhn's "normal science" stage of progress. While the concept of model-based quantification below the nominal imaging resolution is not new, its possibilities in neuroscience and neuroradiology are only beginning to be widely appreciated. This disconnect calls for communicating the progress of tissue microstructure MR imaging to its potential users. Here, a number of recent research developments are outlined in terms of the overarching concept of coarse-graining the tissue structure over an increasing diffusion length. A variety of diffusion models and phenomena are summarized on the phase diagram of diffusion MRI, with the unresolved problems and future directions corresponding to its unexplored domains.