In contrast to BOLD: signal enhancement by extravascular water protons as an alternative mechanism of endogenous fMRI signal change

The current state of spinal cord functional magnetic resonance imaging and its application in clinical research

Since its development, spinal cord functional magnetic resonance imaging (fMRI) has utilized various methodologies and stimulation protocols to develop a deeper understanding of a healthy human spinal cord that lays a foundation for its use in clinical research and practice. In this review, we conducted a comprehensive literature search on spinal cord fMRI studies and summarized the recent advancements and resulting scientific achievements of spinal cord fMRI in the following three aspects: the current state of spinal cord fMRI methodologies and stimulation protocols, knowledge about the healthy spinal cord's functions obtained via spinal cord fMRI, and fMRI's exemplary usage in spinal cord diseases and injuries. We conclude with a discussion that, while technical challenges exist, novel fMRI technologies for and new knowledge about the healthy human spinal cord have been established. Empowered by these developments, investigations of pathological and injury states within the spinal cord have become the next important direction of spinal cord fMRI. Recent clinical investigations into spinal cord pathologies, for example, fibromyalgia, multiple sclerosis, spinal cord injury, and cervical spondylotic myelopathy, have already provided deep insights into spinal cord impairments and the time course of impairment-caused changes. We expect that future spinal cord fMRI advancement and research development will further enhance our understanding of various spinal cord diseases and provide the foundation for evaluating existing and developing new treatment plans.

Integrative Neuroinformatics for Precision Prognostication and Personalized Therapeutics in Moderate and Severe Traumatic Brain Injury

Despite changes in guideline-based management of moderate/severe traumatic brain injury (TBI) over the preceding decades, little impact on mortality and morbidity have been seen. This argues against the "one-treatment fits all" approach to such management strategies. With this, some preliminary advances in the area of personalized medicine in TBI care have displayed promising results. However, to continue transitioning toward individually-tailored care, we require integration of complex "-omics" data sets. The past few decades have seen dramatic increases in the volume of complex multi-modal data in moderate and severe TBI care. Such data includes serial high-fidelity multi-modal characterization of the cerebral physiome, serum/cerebrospinal fluid proteomics, admission genetic profiles, and serial advanced neuroimaging modalities. Integrating these complex and serially obtained data sets, with patient baseline demographics, treatment information and clinical outcomes over time, can be a daunting task for the treating clinician. Within this review, we highlight the current status of such multi-modal omics data sets in moderate/severe TBI, current limitations to the utilization of such data, and a potential path forward through employing integrative neuroinformatic approaches, which are applied in other neuropathologies. Such advances are positioned to facilitate the transition to precision prognostication and inform a top-down approach to the development of personalized therapeutics in moderate/severe TBI.

What Has Been Learned from Magnetic Resonance Imaging Examination of the Injured Human Spinal Cord: A Canadian Perspective

Magnetic resonance imaging (MRI) has transformed the way surgeons and researchers study and treat spinal cord injury. In this narrative review, we explore the historical context of imaging the human spinal cord and describe how MRI has evolved from providing the first visualization of the human spinal cord in the 1980s to a remarkable set of imaging tools today. The article focuses in particular on the role of Canadian researchers to this field. We begin by outlining the clinical context of traumatic injury to the human spinal cord and describe why current MRI standards fall short when it comes to treating this disabling condition. Parts 2 and 3 of this work explore an exciting and dramatic shift in the use of MRI technology to aid in our understanding and treatment of traumatic injury to the spinal cord. We explore the use of functional imaging (part 2) and structural imaging (part 3) and explore how these techniques have evolved, how they are used, and the challenges that we face for continued refinement and application to patients who live with the neurological and functional deficits caused by injury to the delicate spinal cord.

Imaging of the spine: Where do we stand?

The number of patients presenting with spine-related problems has globally increased, with an enormous growing demand for the use of medical imaging to address this problem. The last three decades witnessed great leaps for diagnostic imaging modalities, including those exploited for imaging the spine. These developments improved our diagnostic capabilities in different spinal pathologies, especially with multi-detector computed tomography and magnetic resonance imaging, via both hardware and software improvisations. Nowadays, imaging may depict subtle spinal instability caused by various osseous and ligamentous failures, and could elucidate dynamic instabilities. Consequently, recent diagnostic modalities can discern clinically relevant spinal canal stenosis. Likewise, improvement in diagnostic imaging capabilities revolutionized our understanding of spinal degenerative diseases via quantitative biomarkers rather than mere subjective perspectives. Furthermore, prognostication of spinal cord injury has become feasible, and this is expected to be translated into better effective patient tailoring to management plans with better clinical outcomes. Meanwhile, our confidence in diagnosing spinal infections and assessing the different spinal instrumentation has greatly improved over the past few last decades. Overall, revolutions in diagnostic imaging over the past few decades have upgraded spinal imaging from simple subjective and qualitative indices into a more sophisticated yet precise era of objective metrics via deploying quantitative imaging biomarkers.

Functional Neuroimaging of Nociceptive and Pain-Related Activity in the Spinal Cord and Brain: Insights From Neurovascular Coupling Studies

Spinal cord and brain processes underlie pain perception, which produces systemic cardiovascular changes. In turn, the autonomic nervous system regulates vascular function in the spinal cord and brain in order to adapt to these systemic changes, while neuronal activity induces local vascular changes. Thus, autonomic regulation and pain processes in the brain and spinal cord are tightly linked and interrelated. The objective of this topical review is to discuss work on neurovascular coupling during nociceptive processing in order to highlight supporting evidence and limitations for the use of cerebral and spinal fMRI to investigate pain mechanisms and spinal nociceptive processes. Work on functional neuroimaging of pain is presented and discussed in relation to available neurovascular coupling studies and related issues. Perspectives on future work are also discussed with an emphasis on differences between the brain and the spinal cord and on different approaches that may be useful to improve current methods, data analyses and interpretation. In summary, this review highlights the lack of data on neurovascular coupling during nociceptive stimulation and indicates that hemodynamic and BOLD responses measured with fMRI may be biased by nonspecific vascular changes. Future neuroimaging studies on nociceptive and pain-related processes would gain further understanding of neurovascular coupling in the brain and spinal cord and should take into account the effects of systemic vascular changes that may affect hemodynamic responses. Anat Rec, 301:1585-1595, 2018. © 2018 Wiley Periodicals, Inc.

Generating facial expressions of disgust activates neurons in the thoracic spinal cord: a spinal fMRI study

Facial expressions of disgust, which involve movement of the levator labii muscles on the nose, allow an organism to restrict the intake of potentially aversive stimuli by constricting the air cavities in the nostrils and reducing the speed of air intake. In the current research, we used fMRI of the thoracic spinal cord to measure neural activity related to (1) the contraction of the intercostal muscles that modulate the velocity of air intake and (2) the sensory feedback associated with this contraction. Thirteen participants completed two spinal fMRI runs in which the thoracic segments of the spinal cord were measured. Each five-minute 40-second run consisted of three 60-second blocks in which participants repeatedly generated a disgusted facial expression or a non-emotional expression consisting of repeated stretching of the lips (which did not involve the nasal cavity). Forty-second rest blocks were interleaved between each expression block. The results demonstrated that generating emotional expressions of disgust produces significantly more activity than producing non-emotional facial expressions. This activity occurred in both ventral (motoric) and dorsal (sensory) regions of the upper segments of the thoracic spinal cord and demonstrates a link between the generation of facial expressions and embodied emotional responses.

Nuisance Regression of High-Frequency Functional Magnetic Resonance Imaging Data: Denoising Can Be Noisy

Recently, emerging studies have demonstrated the existence of brain resting-state spontaneous activity at frequencies higher than the conventional 0.1 Hz. A few groups utilizing accelerated acquisitions have reported persisting signals beyond 1 Hz, which seems too high to be accommodated by the sluggish hemodynamic process underpinning blood oxygen level-dependent contrasts (the upper limit of the canonical model is ∼0.3 Hz). It is thus questionable whether the observed high-frequency (HF) functional connectivity originates from alternative mechanisms (e.g., inflow effects, proton density changes in or near activated neural tissue) or rather is artificially introduced by improper preprocessing operations. In this study, we examined the influence of a common preprocessing step-whole-band linear nuisance regression (WB-LNR)-on resting-state functional connectivity (RSFC) and demonstrated through both simulation and analysis of real dataset that WB-LNR can introduce spurious network structures into the HF bands of functional magnetic resonance imaging (fMRI) signals. Findings of present study call into question whether published observations on HF-RSFC are partly attributable to improper data preprocessing instead of actual neural activities.

A Hitchhiker's Guide to Functional Magnetic Resonance Imaging

Functional Magnetic Resonance Imaging (fMRI) studies have become increasingly popular both with clinicians and researchers as they are capable of providing unique insights into brain functions. However, multiple technical considerations (ranging from specifics of paradigm design to imaging artifacts, complex protocol definition, and multitude of processing and methods of analysis, as well as intrinsic methodological limitations) must be considered and addressed in order to optimize fMRI analysis and to arrive at the most accurate and grounded interpretation of the data. In practice, the researcher/clinician must choose, from many available options, the most suitable software tool for each stage of the fMRI analysis pipeline. Herein we provide a straightforward guide designed to address, for each of the major stages, the techniques, and tools involved in the process. We have developed this guide both to help those new to the technique to overcome the most critical difficulties in its use, as well as to serve as a resource for the neuroimaging community.

fMRI Localization of Spinal Cord Processing Underlying Female Sexual Arousal

Using functional magnetic resonance imaging, the authors aimed to determine the roles of the human spinal cord in mediating sexual responses in women. Functional magnetic resonance imaging of the entire lower thoracic, lumbar, and sacral spinal cord was performed using a sexual stimulation paradigm designed to elicit psychological and physical components of sexual arousal. Responses were measured in 9 healthy adult women during 3 consecutive conditions: (a) erotic audiovisual, (b) manual clitoral, and (c) audiovisual plus manual stimulation. Functional magnetic resonance imaging results in healthy subjects demonstrate that this method is sensitive for mapping sexual function in the spinal cord, and identify several key regions involved in human sexual response, including the intermediolateral cell column, the dorsal commissural nucleus, and the sacral parasympathetic nucleus. Using spinal functional magnetic resonance imaging, this study identified many of the spinal cord regions involved in female sexual responses. Results from audiovisual and manual clitoral stimulation correspond with previous data regarding lumbar and sacral neurologic changes during sexual arousal. This study provides the first characterization of neural activity in the human spinal cord underlying healthy female sexual responses and sets a foundation for future studies aimed at mapping changes that result from sexual dysfunction, spinal cord trauma or disease.

Assessing Nociception by fMRI of the Human Spinal Cord: A Systematic Review

OBJECTIVE

To assess the use of fMRI of the spinal cord in measuring noxious stimulation.

METHODS

The Scopus, Medline, EMBASE, and Web of Science databases were searched, along with the reference lists of included articles. Two independent reviewers screened abstracts, full-text articles, and extracted data. Original research was included if fMRI of the human spinal cord was used to measure responses to noxious stimulation.

RESULTS

Of the 192 abstracts screened, 19 met the search criteria and were divided according to their focus: investigating pain responses (n = 6), methodology (n = 6), spinal cord injury (n = 2), or cognition–pain interactions (n = 5). All but one study appear to have observed activity in ipsilateral and dorsal gray matter regions in response to noxious stimuli, although contralateral or ventral activity was also widely observed.

CONCLUSIONS

Although nociception can be investigated using spinal fMRI, establishing reliability, standardizing methodology, and reporting of results will greatly advance this field.

BOLD fractional contribution to resting-state functional connectivity above 0.1 Hz

Blood oxygen level dependent (BOLD) spontaneous signals from resting-state (RS) brains have typically been characterized by low-pass filtered timeseries at frequencies ≤ 0.1 Hz, and studies of these low-frequency fluctuations have contributed exceptional understanding of the baseline functions of our brain. Very recently, emerging evidence has demonstrated that spontaneous activities may persist in higher frequency bands (even up to 0.8 Hz), while presenting less variable network patterns across the scan duration. However, as an indirect measure of neuronal activity, BOLD signal results from an inherently slow hemodynamic process, which in fact might be too slow to accommodate the observed high-frequency functional connectivity (FC). To examine whether the observed high-frequency spontaneous FC originates from BOLD contrast, we collected RS data as a function of echo time (TE). Here we focus on two specific resting state networks - the default-mode network (DMN) and executive control network (ECN), and the major findings are fourfold: (1) we observed BOLD-like linear TE-dependence in the spontaneous activity at frequency bands up to 0.5 Hz (the maximum frequency that can be resolved with TR=1s), supporting neural relevance of the RSFC at a higher frequency range; (2) conventional models of hemodynamic response functions must be modified to support resting state BOLD contrast, especially at higher frequencies; (3) there are increased fractions of non-BOLD-like contributions to the RSFC above the conventional 0.1 Hz (non-BOLD/BOLD contrast at 0.4-0.5 Hz is ~4 times that at <0.1 Hz); and (4) the spatial patterns of RSFC are frequency-dependent. Possible mechanisms underlying the present findings and technical concerns regarding RSFC above 0.1 Hz are discussed.

Spinal and supraspinal processing of thermal stimuli: an fMRI study

PURPOSE

To assess and characterize responses to innocuous/noxious thermal stimuli and heat allodynia using functional spinal magnetic resonance imaging (spinal fMRI).

MATERIALS AND METHODS

Spinal/supraspinal activation patterns of 16 healthy subjects were investigated by applying painful and nonpainful heat stimuli to dermatome C6 baseline and after sensitization with the heat/capsaicin model using fMRI (3T, single-shot TSE, TR 9000 msec, TE 38 msec, FOV 288 × 144 × 20 mm, matrix 192 × 96, voxel size 1 × 1 × 2 mm).

RESULTS

Increased activity was observed in ipsi- and contralateral ventral and dorsal spinal horn during noxious heat and heat allodynia. During noxious heat, but not during heat allodynia, activations were visible in the periaqueductal gray, ipsilateral cuneiform nucleus, and ipsilateral dorsolateral pontine tegmentum (DLPT). However, during heat allodynia activations were observed in bilateral ruber nuclei, contralateral DLPT, and rostral ventromedial medulla oblongata (RVM). Activations in contralateral subnucleus reticularis dorsalis (SRD) were visible during both noxious heat and heat allodynia (T >2.5, P < 0.01 for all of the above). After sensitization, activations in RVM and SRD correlated with activations in the ipsilateral dorsal horn of the spinal cord (R = 0.52-0.98, P < 0.05).

CONCLUSION

Spinal fMRI successfully demonstrates increased spinal activity and secondary changes in activation of supraspinal centers involved in pain modulation caused by peripheral nociceptor sensitization. J. Magn. Reson. Imaging 2015;41:1046-1055. © 2014 Wiley Periodicals, Inc.

Inhibition of aquaporin-4 significantly increases regional cerebral blood flow

The effects of the aquaporin-4 (AQP-4) inhibitor TGN-020 on regional cerebral blood flow (rCBF) was examined in wild-type (WT) and AQP-4 knockout (KO) mice in vivo. Although baseline absolute rCBF of WT and KO mice were equivalent (158.9 ± 17.7 and 155.5 ± 10.4 ml/100 g/min, respectively), TGN-020 produced a significant increase in rCBF compared with saline-treated WT mice (control), reaching a plateau 20 min after administration (118.45 ± 8.13%, P<0.01). TGN-020 showed no effect on KO mice, supporting the concept that the observed increase in rCBF in WT mice was AQP-4 dependent. Administration of acetazolamide (positive control) produced an even greater increase in rCBF in WT compared with TGN-020 and a similar response in KO mice as well, reaching a sustained plateau 5 min after administration (138.50 ± 9.75 and 138.52 ± 9.76%, respectively, P<0.01 compared with baseline or saline-treated control mice). The study demonstrated that AQP-4 plays a role in regulation of rCBF.

Functional magnetic resonance imaging with an ultrashort echo time

PURPOSE

The purpose of the authors study was to investigate a functional MRI (fMRI) technique with an ultrashort echo-time (UTE) sequence.

METHODS

An UTE-based fMRI technique was applied to 17 young healthy volunteers during visual stimulations on a 3T MRI system. In addition, a blood oxygen level-dependent (BOLD) fMRI image was also obtained to compare functional changes in the brain. The one-sample t-test was performed to investigate increased or decreased signals during baseline and stimulation conditions for all subjects. Furthermore, regions-of-interest were placed by selecting one of the peak activated voxels from the UTE-based and BOLD data to investigate the level of signal changes on the time-course.

RESULTS

During the visual activation period, the decreased signals were shown in the visual cortex for the UTE-based method, while both increased and decreased signals were found in the cortex for the BOLD method. The averaged signal changes for the UTE-based data were -0.48 ± 0.37% in the left lingual gyrus, while the changes on the BOLD data were 1.71 ± 0.87% in the right lingual gyrus.

CONCLUSIONS

The UTE-based fMRI technique can detect the neuronal activity corresponding to neuronal function. The UTE-based method should be able to improve spatial localization and has much lower sensitivity to field inhomogeneities. Therefore, UTE-based fMRI can be useful to the neurosciences and clinical populations.

The current state-of-the-art of spinal cord imaging: methods

A first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging, the current greatest challenges, and greatest needs for future development. This meeting was attended by a small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinical practice. The greatest current challenges for spinal cord imaging were identified as arising from the imaging environment itself; difficult imaging environment created by the bone surrounding the spinal canal, physiological motion of the cord and adjacent tissues, and small cross-sectional dimensions of the spinal cord, exacerbated by metallic implants often present in injured patients. Challenges were also identified as a result of a lack of "critical mass" of researchers taking on the development of spinal cord imaging, affecting both the rate of progress in the field, and the demand for equipment and software to manufacturers to produce the necessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlying theory and challenges, and present the evidence for the current and potential power of these methods. In two review papers (part I and part II), we propose that the challenges can be overcome with advances in methods, improving availability and effectiveness of methods, and linking existing researchers to create the necessary scientific and clinical network to advance the rate of progress and impact of the research.

Functional MRI of the thoracic spinal cord during vibration sensation

PURPOSE

To demonstrate that it is possible to acquire accurate functional magnetic resonance images from thoracic spinal cord neurons.

MATERIALS AND METHODS

The lower thoracic spinal dermatomes (T7-T11) on the right side of the body were mechanically stimulated by vibration for 15 participants. Neuronal responses to vibration sensation were measured in the thoracic spinal cord using a HASTE sequence on a 3 Tesla MRI system.

RESULTS

Signal increases were observed in the corresponding lower thoracic spinal cord segments ipsilateral to the side of stimulation in the dorsal aspect of the spinal cord.

CONCLUSION

This is the first study to provide proof of principle that functional imaging of the entire thoracic spinal cord is possible, by detecting neuronal activity in the thoracic spinal cord during sensory stimulation using spinal fMRI.

A systematic review of spinal fMRI research: outlining the elements of experimental design

Object

Since the first published report of spinal functional MRI (fMRI) in humans in 1996, this body of literature has grown substantially. In the present article, the authors systematically review all spinal fMRI studies conducted in healthy individuals with a focus on the different motor and sensory paradigms used and the results acquired.

Methods

The authors conducted a systematic search of MEDLINE for literature published from 1990 through November 2011 reporting on stimulation paradigms used to assess spinal fMRI scans in healthy individuals.

Results

They identified 19 peer-reviewed studies from 1996 to the present in which a combination of different spinal fMRI methods were used to investigate the spinal cord in healthy individuals. Eight of the studies used a motor stimulation paradigm, 10 used a sensory stimulation paradigm, and 1 compared motor and sensory stimulation paradigms.

Conclusions

Despite differences in the results of various studies, even when similar stimulation paradigms were used, this body of literature underscores that spinal fMRI signals can be obtained from the human spinal cord. The authors intend this review to serve as an introduction to spinal fMRI research and what it may offer the field of spinal cord injury research.

Measurement and characterization of the human spinal cord SEEP response using event-related spinal fMRI

Although event-related fMRI is able to reliably detect brief changes in brain activity and is now widely used throughout systems and cognitive neuroscience, there have been no previous reports of event-related spinal cord fMRI. This is likely attributable to the various technical challenges associated with spinal fMRI (e.g., imaging a suitable length of the cord, reducing image artifacts from the vertebrae and intervertebral discs, and dealing with physiological noise from spinal cord motion). However, with many of these issues now resolved, the largest remaining impediment for event-related spinal fMRI is a deprived understanding of the spinal cord fMRI signal time course. Therefore, in this study, we used a proton density-weighted HASTE sequence, with functional contrast based on signal enhancement by extravascular water protons (SEEP), and a motion-compensating GLM analysis to (i) characterize the SEEP response function in the human cervical spinal cord and (ii) demonstrate the feasibility of event-related spinal fMRI. This was achieved by applying very brief (1 s) epochs of 22°C thermal stimulation to the palm of the hand and measuring the impulse response function. Our results suggest that the spinal cord SEEP response (time to peak ≈8 s; FWHM ≈4 s; and probably lacking pre- and poststimulus undershoots) is slower than previous estimates of SEEP or BOLD responses in the brain, but faster than previously reported spinal cord BOLD responses. Finally, by detecting and mapping consistent signal-intensity changes within and across subjects, and validating these regions with a block-designed experiment, this study represents the first successful demonstration of event-related spinal fMRI.

Neural correlates of sexual arousal in the spinal cords of able-bodied men: a spinal fMRI investigation

The purpose of this study was to determine whether spinal cord functional magnetic resonance imaging could be used to map neural activity throughout the lower thoracic, lumbar, and sacral spinal cord regions during sexual arousal in healthy men. The authors found that viewing erotic films and genital self-stimulation elicited predominantly increased signal, indicative of amplified neuronal input to the dorsal and ventral horns and in the autonomic preganglionic nuclei of the lower thoracic, lumbar, and sacral spinal cord. In addition, linear regression analyses revealed a number of robust correlations (|R| ≥ 0.7) between signal intensity changes in these spinal cord regions and self-reported ratings of mental and physical sexual arousal. Taken together, these results demonstrate that spinal cord functional magnetic resonance imaging is an effective and sensitive technique for mapping the neural correlates of sexual arousal in the spinal cords of able-bodied men. Most important, the results from this study indicate that spinal cord functional magnetic resonance imaging may have important applications as a clinical tool for assessing and mapping the changes that occur in the spinal cords of men suffering from sexual dysfunction as a result of spinal cord trauma.

Development of a Novel Ligand, [C]TGN-020, for Aquaporin 4 Positron Emission Tomography Imaging

Aquaporin 4 (AQP4), the most abundant isozyme of the water specific membrane transporter aquaporin family, has now been implicated to play a significant role in the pathogenesis of various disease processes of the nervous system from epilepsy to Alzheimer’s disease. Considering its clinical relevance, it is highly desirable to develop a noninvasive method for the quantitative analysis of AQP distribution in humans under clinical settings. Currently, the method of choice for such diagnostic examinations continues to be positron emission tomography (PET). Here, we report the successful development of a PET ligand for AQP4 imaging based on TGN-020, a potent AQP4 inhibitor developed previously in our laboratory. Utilizing [¹¹C]-TGN-020, PET images were successfully generated in wild type and AQP4 null mice, providing a basis for future evaluation regarding its suitability for clinical studies.

Applying functional MRI to the spinal cord and brainstem

Functional magnetic resonance imaging of the spinal cord (spinal fMRI) has facilitated the noninvasive visualization of neural activity in the spinal cord (SC) and brainstem of both animals and humans. This technique has yet to gain the widespread usage of brain fMRI, due in part to the intrinsic technical challenges spinal fMRI presents and to the narrower scope of applications it fulfills. Nonetheless, methodological progress has been considerable and rapid. To date, spinal fMRI studies have investigated SC function during sensory or motor task paradigms in spinal cord injury (SCI), multiple sclerosis (MS) and neuropathic pain (NP) patient populations, all of which have yielded consistent and sensitive results. The most recent study in our laboratory has successfully used spinal fMRI to examine cervical SC activity in a SCI patient with a metallic fixation device spanning the C(4) to C(6) vertebrae, a critical step in realizing the clinical utility of the technique. The literature reviewed in this article suggests that spinal fMRI is poised for usage in a wide range of patient populations, as multiple groups have observed intriguing, yet consistent, results using standard, readily available MR systems and hardware. The next step is the implementation of this technique in the clinic to supplement standard qualitative behavioral assessments of SCI. Spinal fMRI may offer insight into the subtleties of function in the injured and diseased SC, and support the development of new methods for treatment and monitoring.