Magnetic Resonance Spectroscopy In Cerebral Ischemia

Clinical magnetic resonance spectroscopy of the central nervous system

Proton magnetic resonance spectroscopy (1H MRS) is a noninvasive imaging technique that can easily be added to the conventional magnetic resonance (MR) imaging sequences. Using MRS one can directly compare spectra from pathologic or abnormal tissue and normal tissue. Metabolic changes arising from pathology that can be visualized by MRS may not be apparent from anatomy that can be visualized by conventional MR imaging. In addition, metabolic changes may precede anatomic changes. Thus, MRS is used for diagnostics, to observe disease progression, monitor therapeutic treatments, and to understand the pathogenesis of diseases. MRS may have an important impact on patient management. The purpose of this chapter is to provide practical guidance in the clinical application of MRS of the brain. This chapter provides an overview of MRS-detectable metabolites and their significance. In addition some specific current clinical applications of MRS will be discussed, including brain tumors, inborn errors of metabolism, leukodystrophies, ischemia, epilepsy, and neurodegenerative diseases. The chapter concludes with technical considerations and challenges of clinical MRS.

Field dependence study of in vivo brain (31) P MRS up to 16.4 T

In vivo (31) P MRS provides a unique tool for studying bioenergetics of living organs. Although its utility has been limited by the relatively low (31) P NMR sensitivity, increasing magnetic field strength (B0 ) could significantly improve the quality and reliability of the (31) P MR spectra for biomedical research. To quantitatively understand the field dependence of in vivo (31) P MRS for brain applications, (31) P NMR sensitivity of phosphocreatine (PCr) in rat brains was measured and compared at 9.4 T and 16.4 T. Additionally, the linewidths and T1 relaxation times of PCr and adenosine triphosphate (ATP) resonances obtained from human and animal brains over a wide B0 range from 4 T, 7 T, and 9.4 T to 16.4 T were examined and their field dependences were quantified. The results indicate an approximate 1.74-fold (31) P signal-to-noise ratio (SNR) gain for PCr at 16.4 T compared with 9.4 T. An approximate power 1.4 dependence of (31) P SNR on B0 was concluded. Substantial improvements in spectral resolution and significantly shortened T1 values of brain PCr and ATP were observed at high/ultrahigh fields, contributing to an additional sensitivity gain and spectral improvement. In summary, the overall findings from this study suggest that in vivo (31) P MRS should greatly benefit from high/ultrahigh fields for noninvasive assessment of altered bioenergetics and metabolic processes associated with brain function and neurological diseases.

pH as a biomarker of neurodegeneration in Huntington's disease: a translational rodent-human MRS study

Early diagnosis and follow-up of neurodegenerative diseases are often hampered by the lack of reliable biomarkers. Neuroimaging techniques like magnetic resonance spectroscopy (MRS) offer promising tools to detect biochemical alterations at early stages of degeneration. Intracellular pH, which can be measured noninvasively by (31)P-MRS, has shown variations in several brain diseases. Our purpose has been to evaluate the potential of MRS-measured pH as a relevant biomarker of early degeneration in Huntington's disease (HD). We used a translational approach starting with a preclinical validation of our hypothesis before adapting the method to HD patients. (31)P-MRS-derived cerebral pH was first measured in rodents during chronic intoxication with 3-nitropropionic acid (3NP). A significant pH increase was observed early into the intoxication protocol (pH=7.17±0.02 after 3 days) as compared with preintoxication (pH=7.08±0.03). Furthermore, pH changes correlated with the 3NP-induced inhibition of succinate dehydrogenase and preceded striatum lesions. Using a similar MRS approach implemented on a clinical MRI, we then showed that cerebral pH was significantly higher in HD patients (n=7) than in healthy controls (n=6) (7.05±0.03 versus 7.02±0.01, respectively, P=0.026). Altogether, both preclinical and human data strongly argue in favor of MRS-measured pH being a promising biomarker for diagnosis and follow-up of HD.

Advanced In Vivo Heteronuclear MRS Approaches for Studying Brain Bioenergetics Driven by Mitochondria

The greatest merit of in vivo magnetic resonance spectroscopy (MRS) methodology used in biomedical research is its ability for noninvasively measuring a variety of metabolites inside a living organ. It, therefore, provides an invaluable tool for determining metabolites, chemical reaction rates and bioenergetics, as well as their dynamic changes in the human and animal. The capability of in vivo MRS is further enhanced at higher magnetic fields because of significant gain in detection sensitivity and improvement in the spectral resolution. Recent progress of in vivo MRS technology has further demonstrated its great potential in many biomedical research areas, particularly in brain research. Here, we provide a review of new developments for in vivo heteronuclear 31P and 17O MRS approaches and their applications in determining the cerebral metabolic rates of oxygen and ATP inside the mitochondria, in both animal and human brains.

In vivo 31P MRS of human brain at high/ultrahigh fields: a quantitative comparison of NMR detection sensitivity and spectral resolution between 4 T and 7 T

The primary goal of this study was to establish a rigorous approach for determining and comparing the NMR detection sensitivity of in vivo 31P MRS at different field strengths (B0). This was done by calculating the signal-to-noise ratio (SNR) achieved within a unit sampling time at a given field strength. In vivo 31P spectra of human occipital lobe were acquired at 4 and 7 T under similar experimental conditions. They were used to measure the improvement of the human brain 31P MRS when the field strength increases from 4 to 7 T. The relaxation times and line widths of the phosphocreatine (PCr) resonance peak and the RF coil quality factors (Q) were also measured at these two field strengths. Their relative contributions to SNR at a given field strength were analyzed and discussed. The results show that in vivo 31P sensitivity was significantly improved at 7 T as compared with 4 T. Moreover, the line-width of the PCr resonance peak showed less than a linear increase with increased B0, which leads to a significant improvement in 31P spectral resolution. These findings indicate the advantage of high-field strength to improve in vivo 31P MRS quality in both sensitivity and spectral resolution. This advantage should improve the reliability and applicability of in vivo 31P MRS in studying high-energy phosphate metabolism, phospholipid metabolism and cerebral biogenetics in the human at both normal and diseased states noninvasively. Finally, the approach used in this study for calculating in vivo 31P MRS sensitivity provides a general tool in estimating the relative NMR detection sensitivity for any nuclear spin at a given field strength.

Imaging of cerebral blood flow and metabolism

PURPOSE OF REVIEW

To review the techniques for imaging cerebral blood flow and metabolism following injury to the brain.

RECENT FINDINGS

Xenon enhanced computerized tomography (Xenon CT), CT perfusion and single photon emission CT provide measurements of cerebral perfusion, while positron emission tomography (PET), and magnetic resonance imaging and spectroscopy (MRI and MRS) are able to assess both perfusion and cerebral metabolism. Xenon CT and CT perfusion are readily available and have proved useful in a variety of causes of brain injury. PET is an extremely useful research tool for defining cerebral physiology, but is limited in its availability. Despite the continuing development of MRI and MRS imaging, the scanning environment remains hostile for critically ill patients, and further research is required before the techniques become generally available.

SUMMARY

Imaging of cerebral blood flow and metabolism has been shown to be useful following a variety of causes of brain injury, as it can help to define the cause and extent of injury, identify appropriate treatments and predict outcome. Imaging based on CT techniques (Xenon CT and CT perfusion) can be implemented easily in most hospital centres, and are able to provide quantitative perfusion data in addition to structural images.

Cerebral hemodynamics and metabolism in patients with symptomatic occlusion of the internal carotid artery

BACKGROUND AND PURPOSE

The goals of this study were to investigate (1) whether the concentrations of choline, creatine, and N-acetyl aspartate (NAA) in cerebral white matter are changed in patients with symptomatic occlusion of the internal carotid artery (ICA) and (2) whether possible changes in metabolite concentration are related to regional cerebral perfusion or cerebral vasoreactivity.

METHODS

In 19 patients (mean+/-SD age, 60+/-9 years), white matter metabolite concentrations were measured with proton MR spectroscopic imaging on average 4+/-2 months after symptoms occurred. In selected voxels, corresponding cerebral blood flow and volume, mean transit time, and time-to-bolus peak were determined with dynamic susceptibility contrast MRI. Cerebral CO2 reactivity was determined with transcranial Doppler sonography.

RESULTS

No significant changes in choline and creatine concentrations were observed. NAA concentration was significantly reduced in the hemisphere on the side of the symptomatic ICA (9.1+/-1.7 mmol/L) compared with the contralateral hemisphere (10.5+/-1.7 mmol/L, P<0.005) and control subjects (10.5+/-0.9 mmol/L, P<0.01). Although no significant interhemispheric difference in NAA concentration was found in patients who presented with retinal ischemia, patients with cerebral ischemia had a significantly lower NAA concentration in the symptomatic hemisphere (9.0+/-1.7 mmol/L) compared with the asymptomatic hemisphere (10.4+/-1.6 mmol/L, P<0.05). In all patients, NAA concentration was not significantly correlated with quantitative cerebral perfusion parameters or CO2 reactivity.

CONCLUSIONS

Patients with symptomatic ICA occlusion may show chronic neuronal damage in cerebral white matter as evidenced by reduced NAA concentration. This seems to be related to previous symptomatology rather than to the cerebral hemodynamic status in a chronic stage.

Application of magnetic resonance to animal models of cerebral ischemia

The present review has been compiled to highlight the role of magnetic resonance imaging (MRI) and MR spectroscopy (MRS) for the investigation of cerebral ischemia in the animal experimental field of basic research. We have focused on stroke investigations analyzing the pathomechanisms of the disease evolution and on new advances in both nuclear MR (NMR) methodology or genetic engineering of transgenic animals for the study of complex molecular relationships and causes of the disease. Furthermore, we have tried to include metabolic and genetic aspects, as well as the application of functional imaging, for the investigation of the disturbance or restitution of functional brain activation under pathological conditions as relates to controlled animal experiments.

Cerebral T1rho relaxation time increases immediately upon global ischemia in the rat independently of blood glucose and anoxic depolarization

Time-dependent changes of T1 in the rotating frame (T1rho), diffusion, T2, and magnetization transfer contrast on cardiac arrest-induced global ischemia in rat were investigated. T1rho, as acquired with spin lock amplitudes >0.6 G, started to increase 10-20 sec after cardiac arrest followed by an increase within 3-4 min to a level that was 6-8% greater than in normal brain. The ischemic T1rho response coincided with the drop of water diffusion coefficient in normoglycemic animals. However, unlike the rate of diffusion, the kinetics of T1rho were not affected by either preischemic hypoglycemia or hyperglycemia. Similar to diffusion, the kinetics of anoxic depolarization were dependent on preischemic blood glucose levels. Ischemia caused a reduction in the Hahn spin echo T2 as a result of blood oxygenation level-dependent (BOLD) effect; maximal negative BOLD seen by 40 sec. In the animals injected with an ironoxide particle contrast agent, AMI-227, prior to the insult, both T1rho and T2 immediately increased in concert on induction of ischemia. In contrast to the T1rho and diffusion changes, a much slower change in magnetization transfer contrast was evident over the first 20 min of ischemia. These data demonstrate that T1rho immediately increases following ischemia and that the pathophysiological mechanisms affecting this relaxation time may not directly involve magnetization transfer. The mechanisms prolonging T1rho differ from those affecting water diffusion with respect to their sensitivities to glucose and are apparently independent of membrane depolarization.

Cerebral metabolic changes in patients with a symptomatic occlusion of the internal carotid artery: a longitudinal 1H magnetic resonance spectroscopy study

The objective of this 1H magnetic resonance spectroscopy study was to investigate the time course of the brain metabolites N-acetyl-aspartate (NAA), choline, and lactate in patients with transient or minor disabling neurological deficits associated with an occlusion of the internal carotid artery (ICA). Fifty patients had had symptoms of hemispheric ischemia, and 16 had suffered symptoms of retinal ischemia. Single-voxel proton spectra were obtained from uninfarcted cerebral regions on three occasions: 0-6, 6-12, and 12-18 months after symptoms. Reference values were obtained from 29 control subjects. In the 0-6 month period, patients with hemispheric ischemia showed a significantly lower NAA/creatine ratio in the hemisphere ipsilateral to the ICA occlusion, compared with control subjects and patients with retinal ischemia, and a significantly higher choline/creatine ratio, compared with control subjects. The prevalence of lactate did not differ significantly between patient groups. In the following time periods, the NAA/creatine ratio in patients with hemispheric ischemia tended to return to control values and no longer differed from that in patients with retinal ischemia; the choline/creatine ratio decreased significantly and returned to control values. These results demonstrate that cerebral metabolism is altered in patients with an ICA occlusion who have had a hemispheric ischemic event, but returns (choline) or tends to return (NAA) to control values over time. The metabolic changes occur primarily in the hemisphere ipsilateral to the symptomatic ICA occlusion and are related to the occurrence of the hemispheric ischemic event.

Cerebral metabolism in experimental hydrocephalus: an in vivo 1H and 31P magnetic resonance spectroscopy study

OBJECT

Brain damage in patients with hydrocephalus is caused by mechanical forces and cerebral ischemia. The severity and localization of impaired cerebral blood flow and metabolism are still largely unknown. Magnetic resonance (MR) spectroscopy offers the opportunity to investigate cerebral energy metabolism and neuronal damage noninvasively and longitudinally. Previous 1H MR spectroscopy studies have shown an increased lactate resonance that is suggestive of anaerobic glycolysis. The aim of this study was to assess cerebral damage and energy metabolism in kaolin-induced hydrocephalus in adult rats by using in vivo 1H and 31P MR spectroscopy. The presence of lactate was correlated with high-energy phosphate metabolism and intracellular pH. The measurement of relative concentrations of N-acetyl aspartate (NAA), choline (Cho), and total creatine (tCr) served to assess neuronal damage.

METHODS

Hydrocephalus was induced in adult rats by surgical injection of kaolin into the cisterna magna. Magnetic resonance studies, using a 4.7-tesla magnet, were performed longitudinally in hydrocephalic animals at 1 (10 rats), 8 (six rats), and 16 weeks (six rats) thereafter, as well as in eight control animals. To evaluate ventricular size and white matter edema T2-weighted MR imaging was performed. The 1H MR spectra were acquired from a 240-microl voxel, positioned centrally in the brain, followed by localized 31P MR spectroscopy on a two-dimensional column that contained the entire brain but virtually no extracranial muscles. The 1H and 31P MR spectroscopy peak ratios were calculated after fitting the spectra in the time domain, intracellular pH was estimated from the inorganic phosphate (Pi) chemical shift, and T2 relaxation times of 1H metabolites were determined from the signal decay at increasing echo times.

CONCLUSIONS

In hydrocephalic rats, ventricular expansion stabilized after 8 weeks. White matter edema was most pronounced during acute hydrocephalus. Lactate peaks were increased at all time points, without a decrease in phosphocreatine (PCr)/Pi and PCr/adenosine triphosphate (ATP) peak ratios, or pH. Possibly lactate production is restricted to periventricular brain tissue, followed by its accumulation in cerebrospinal fluid, which is supported by the long lactate T2 relaxation time. Alternatively, lactate production may precede impairment of ATP homeostasis. The NAA/Cho and tCr/Cho ratios significantly decreased during the acute and chronic stages of hydrocephalus. These changes were not caused by alterations in metabolite T2 relaxation time. The decreases in the NAA/Cho and tCr/Cho ratios implicate neuronal loss/dysfunction or changes in membrane phospholipid metabolism, as in myelin damage or gliosis. It is suggested that 1H MR spectroscopy can be of additional value in the assessment of energy metabolism and cerebral damage in clinical hydrocephalus.

Carotid occlusive disease and stroke risk in coronary artery bypass graft surgery

To clarify the perioperative stroke risk in patients with carotid stenosis or occlusion having coronary artery bypass graft (CABG) surgery, we retrospectively reviewed the records of 1,022 patients who had CABG during a 2-year period (1992, 1993). Of these, 224 had preoperative carotid duplex studies, usually for bruit or remote symptoms. We analyzed clinical and neuroimaging findings for all patients who had strokes to determine infarct topography and presumed mechanism, either low perfusion or embolism. Perioperative stroke was always ipsilateral to severe (> or = 70%) carotid disease, and occurred in 2 (8.0%) of 25 patients with carotid occlusion, 3 (50.0%) of 6 patients with 70 to 99% stenosis, and 9 (4.7%) of 193 patients with less than 70% stenosis. Borderzone infarcts occurred with all degrees of carotid stenosis. Stroke frequency had a positive correlation with the degree of carotid stenosis. Eight (1.0%) of the 798 patients not studied by carotid duplex had stroke in various vascular distributions. Overall, stroke occurred in 22 (2.2%) of the 1,022 patients having CABG surgery. Our results suggest that while the overall risk of perioperative stroke in CABG surgery is low, the risk is increased in patients with severe extracranial carotid stenosis or occlusion. The role of carotid disease and the mechanism of borderzone infarction in CABG surgery remain unsettled.

1H-magnetic resonance spectroscopy-determined cerebral lactate and poor neurological outcomes in children with central nervous system disease

By using proton magnetic resonance spectroscopy ((1)H-MRS), cerebral lactate has been shown to be elevated in a wide variety of pediatric and adult neurological diseases. In this study we compared 36 newborns, infants, and children with elevated lactate peaks on (1)H-MRS with 61 patients without an identifiable lactate signal. (1)H-MRS was acquired from the occipital gray and parietal white matter (8 cm3 volume, STEAM sequence with echo time = 20 msec, repetition time = 3.0 seconds) and data were expressed as ratios of different metabolite peak areas (N-acetylaspartate [NA]/creatine [Cr], NA/choline [Ch], and Ch/Cr) and the presence of a characteristic lactate doublet peak at 1.3 ppm. Outcomes (Pediatric Cerebral Performance Category Scale score; PCPCS) were assigned 6 to 12 months after injury. Patients with lactate peaks were more likely to have suffered a cardiac arrest, were more often hyperglycemic, and had lower Glasgow Coma Scale scores on admission. They were also more likely to have abnormal metabolite ratios when compared with age-matched controls or with patients without detectable lactate. Of prognostic importance, patients with increased lactate were more likely to be severely disabled (39% vs 10%), survive in a persistent vegetative state (13% vs 2%), or have died (39% vs 7%). In contrast, patients with similar conditions without increased lactate were more likely to have had a good outcome (23% vs 3%) or recovered to a mild (38% vs 6%) or moderate disability (20% vs 0%). Our data suggest that (1)H-MRS is useful in the prediction of long-term outcomes in children with neurological disorders. Patients with elevated cerebral lactate are more likely to die acutely or are at greater risk for serious long-term disability.

Early determination of neurological outcome after prehospital cardiopulmonary resuscitation

BACKGROUND AND PURPOSE

Although there are various methods of determining neurological prognosis after cardiopulmonary resuscitation, the final outcome of patients often remains unclear for quite a long time.

METHODS

We investigated 30 consecutively admitted patients who had been successfully resuscitated by the team of the local mobile intensive care unit after cardiac arrest. Determinations of the period of anoxia and of the cardiopulmonary resuscitation time, clinical investigation, echocardiography, electroencephalography, evoked potentials, magnetic resonance imaging, and magnetic resonance spectroscopy were performed.

RESULTS

Demonstration of brain lactate in proton magnetic resonance spectroscopy (P < .01) and absent N20 waves in short-latency somatosensory evoked potentials (P < .01) proved to be significant in terms of a poor prognosis. Correlations between both duration of anoxia and cardiopulmonary resuscitation time and neurological outcome could be shown as well (both P < .05).

CONCLUSIONS

Proton magnetic resonance spectroscopy and short-latency evoked potentials are of great benefit in the prognostic evaluation after cardiopulmonary resuscitation.

Stroke study group. Preliminary results. Early intensive care improves functional outcome

Early and intensive care seems to positively affect outcome in stroke patients. A standardized protocol, costly adjusted to our reality and suitable for application by non-specialist at Emergency Room, proved effective, reflecting in diagnosis reliability, reducing time for beginning therapy, leading to low mortality rates and better functional outcomes at discharge.

Decrease in brain choline-containing compounds following a short period of global ischemia in gerbils as detected by 1H NMR spectroscopy in vivo

Cerebral metabolism was studied in the postischaemic gerbil brain using surface coil 31P and 1H NMR spectroscopy. The ratio of choline-containing compounds (Cho) to total creatine (Cr) in the brain decreased from 0.46 +/- 0.02 to 0.32 +/- 0.02 by the fifth day following exposure to 5 min of global ischaemia and it remained at this low level for at least 19 days. The amounts of cerebral Cho as quantified by 1H NMR in vivo were 1.70 +/- 0.15 and 1.09 +/- 0.22 mmol/kg in control and postischaemic animals, respectively. The T2 of Cho was longer in the postischaemic cerebral cortex than in the control one. N-acetyl aspartate (NAA) as determined by 1H NMR in vivo did not differ in the two animal groups. High-resolution 1H NMR of acid-extracted brain cortices showed a decrease in total Cho (glycerophosphocholine, phosphocholine and choline) by 31%, but no changes in NAA, total creatine, taurine and myo-inositol, in the brain cortex seven days postischaemia relative to control animals. The decrease in acid extractable Cho was mainly due to the drop in glycerophosphocholine concentration. 31P NMR indicated normal energy state and phosphomonoester/phosphocreatine (PCr) and phosphodiester/PCr ratios in the in vivo brain 7 days postischaemia. Silver impregnation did not reveal neuronal degeneration but immunohistochemical staining showed a number of glial fibrillary acidic protein expressing astrocytes as indicators of reactive gliosis in the postischaemic cerebral cortex. These data show, for the first time, that a 1H NMR decrease in Cho metabolites takes place as a consequence of brief ischaemic episode even in the absence of obvious neuronal degeneration.

What might be the impact on neurology of the analysis of brain metabolism by in vivo magnetic resonance spectroscopy?

In vivo nuclear magnetic resonance spectroscopy (MRS) of the human brain is a recently developed technique which allows to assay noninvasively in vivo key molecules of brain metabolism. After a review of the origin of the signals detected by phosphorus and proton MRS of human brain, the impact of MRS on clinical neurology is examined. MRS of the brain does not purport to be a metabolic "biopsy", but unique applications for brain MRS are (1) quantitating the oxidative state of the brain and defining neuronal death, (2) assessing and mapping neuron damage, (3) evaluating membrane alterations, and (4) characterizing encephalopathies. In the near future brain MRS will be performed routinely after conventional MRI, as a valuable metabolic (and functional) complement to the anatomical evaluation of cerebral pathologies, particularly the toxic, metabolic and infectious encephalopathies.