Early, evolving Wallerian degeneration of the pyramidal tract in cerebrovascular diseases: MR study

Stroke-Induced Secondary Neurodegeneration of the Corticospinal Tract-Time Course and Mechanisms Underlying Signal Changes in Conventional and Advanced Magnetic Resonance Imaging

Secondary neurodegeneration refers to the final result of several simultaneous and sequential mechanisms leading to the loss of substance and function in brain regions connected to the site of a primary injury. Stroke is one of the most frequent primary injuries. Among the subtypes of post-stroke secondary neurodegeneration, axonal degeneration of the corticospinal tract, also known as Wallerian degeneration, is the most known, and it directly impacts motor functions, which is crucial for the motor outcome. The timing of its appearance in imaging studies is usually considered late (over 4 weeks), but some diffusion-based magnetic resonance imaging (MRI) techniques, as diffusion tensor imaging (DTI), might show alterations as early as within 7 days from the stroke. The different sequential pathological stages of secondary neurodegeneration provide an interpretation of the signal changes seen by MRI in accordance with the underlying mechanisms of axonal necrosis and repair. Depending on the employed MRI technique and on the timing of imaging, different rates and thresholds of Wallerian degeneration have been provided in the literature. In fact, three main pathological stages of Wallerian degeneration are recognizable-acute, subacute and chronic-and MRI might show different changes: respectively, hyperintensity on T2-weighted sequences with corresponding diffusion restriction (14-20 days after the injury), followed by transient hypointensity of the tract on T2-weighted sequences, and by hyperintensity and atrophy of the tract on T2-weighted sequences. This is the main reason why this review is focused on MRI signal changes underlying Wallerian degeneration. The identification of secondary neurodegeneration, and in particular Wallerian degeneration, has been proposed as a prognostic indicator for motor outcome after stroke. In this review, the main mechanisms and neuroimaging features of Wallerian degeneration in adults are addressed, focusing on the time and mechanisms of tissue damage underlying the signal changes in MRI.

Predicting future brain tissue loss from white matter connectivity disruption in ischemic stroke

BACKGROUND AND PURPOSE

The Network Modification (NeMo) Tool uses a library of brain connectivity maps from normal subjects to quantify the amount of structural connectivity loss caused by focal brain lesions. We hypothesized that the Network Modification Tool could predict remote brain tissue loss caused by poststroke loss of connectivity.

METHODS

Baseline and follow-up MRIs (10.7±7.5 months apart) from 26 patients with acute ischemic stroke (age, 74.6±14.1 years, initial National Institutes of Health Stroke Scale, 3.1±3.1) were collected. Lesion masks derived from diffusion-weighted images were superimposed on the Network Modification Tool's connectivity maps, and regional structural connectivity losses were estimated via the Change in Connectivity (ChaCo) score (ie, the percentage of tracks connecting to a given region that pass through the lesion mask). ChaCo scores were correlated with subsequent atrophy.

RESULTS

Stroke lesions' size and location varied, but they were more frequent in the left hemisphere. ChaCo scores, generally higher in regions near stroke lesions, reflected this lateralization and heterogeneity. ChaCo scores were highest in the postcentral and precentral gyri, insula, middle cingulate, thalami, putamen, caudate nuclei, and pallidum. Moderate, significant partial correlations were found between baseline ChaCo scores and measures of subsequent tissue loss (r=0.43, P=4.6×10(-9); r=0.61, P=1.4×10(-18)), correcting for the time between scans.

CONCLUSIONS

ChaCo scores varied, but the most affected regions included those with sensorimotor, perception, learning, and memory functions. Correlations between baseline ChaCo and subsequent tissue loss suggest that the Network Modification Tool could be used to identify regions most susceptible to remote degeneration from acute infarcts.

Natural history and prognostic value of corticospinal tract Wallerian degeneration in intracerebral hemorrhage

BACKGROUND

The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration (CST-WD) in spontaneous intracerebral hemorrhage (ICH) using serial MR imaging.

METHODS AND RESULTS

Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRIs at 2, 7, 14, and 21 days. MRIs were analyzed by independent raters for the presence and topographical distribution of CST-WD on diffusion-weighted imaging (DWI). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score (NIHSS) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale (mRS) and the motor-NIHSS. Twenty-seven patients underwent 93 MRIs; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH, CST-WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST. CST-WD changes evolved into T2-hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRIs obtained after 3 months. In univariate analyses, the presence of CST-WD was associated with poor functional outcome (ie, mRS 4 to 6; P=0.046) and worse motor-NIHSS (5 versus 1, P=0.001) at 3 months.

CONCLUSIONS

Wallerian degeneration along the CST is common in spontaneous supratentorial ICH, particularly in deep ICH. It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST-WD is associated with poor motor and functional recovery after ICH.

Temporal coupling is more robust than spatial coupling: an investigation of interlimb coordination after stroke

Interlimb coordination obtained through temporal and spatial coupling is a significant feature of human motor control. To understand the robustness of this capability the authors introduced a method to quantify interlimb coordination strength and compare individuals with asymmetric effector ability poststroke to nondisabled controls. Quantitative analyses determined the relative strength of interlimb coupling with an asymmetric obstacle avoidance task. Participants performed bimanual discrete, multijoint aiming movements in the frontal plane with a vertical barrier positioned midway to the target for one limb. To quantify coupling strength between limbs and groups, we regressed individual participant nonbarrier limb movement time or maximum vertical displacement separately, on barrier limb performance. Temporal and spatial interlimb coupling strength varied across participants in both groups. Barrier limb performance predicted nonbarrier limb behavior; however, interlimb coupling was significantly stronger for the nondisabled compared to the stroke group. In the stroke group, deficits in interlimb coordination affected spatial coupling more than temporal coupling. The decreased coupling strength detected, even in the presence of mild hemiparesis, demonstrates the measure's sensitivity. The authors propose this metric as a powerful assessment of the effectiveness of rehabilitation interventions and to monitor the recovery of bimanual coordination poststroke.

Association between radiographic Wallerian degeneration and neuropathological changes post childhood stroke

AIM

Wallerian degeneration is a radiological finding thought to reflect corticospinal tract degeneration. This finding on magnetic resonance imaging (MRI) is routinely used as a predictor of poor prognosis in childhood stroke. However, its validity has never been established. Our objective was to correlate Wallerian degeneration seen on MRI with histopathology.

METHOD

We searched the databases of the Department of Pathology and Children's Stroke registry at the Hospital for Sick Children, Toronto for autopsy specimens exhibiting focal infarcts from children born at term who underwent MRI after a stroke. The specimens were examined for Wallerian degeneration and then correlated with the pre-mortem MRI findings.

RESULTS

Seven children (four females, three males) with a median age of 11 years (1-17 y) at the time of stroke met the inclusion criteria for this study. Of the seven children included in the study with ischaemic or haemorrhagic infarcts, six had concordant Wallerian degeneration findings on both MRI and post-mortem histopathological examination. The median time between stroke and death was 20 days (3-1825 d).

INTERPRETATION

Our results show for the first time that the radiographic finding of Wallerian degeneration is a valid biomarker of corticospinal tract degeneration in children who have had ischaemic or haemorrhagic stroke.

Structural damage to the corticospinal tract correlates with bilateral sensorimotor cortex reorganization in stroke patients

Damage to the corticospinal tract (CST) in stroke patients has been associated with functional reorganization in the ipsilesional and contralesional sensorimotor cortices. However, it is unknown whether a quantitative relationship exists between the extent of structural damage to the CST and functional reorganization in stroke patients. The purpose of the current study was to examine the relationship between structural CST damage and motor task-related cortical activity in chronic hemiparetic stroke patients. In 10 chronic hemiparetic stroke patients with heterogeneous lesions, CST damage was quantified using conventional structural magnetic resonance imaging and tractography based on diffusion tensor imaging. Cortical activity was measured using functional magnetic resonance imaging during repetitive flexion/extension movements of the digits. We found that the two measures of CST damage were strongly correlated. Moreover, greater CST damage was significantly and linearly correlated with increased activation during affected hand movement in the hand area of the contralesional primary sensorimotor cortex (M1/S1) and in the ipsilesional M1/S1 ventral to the hand area. To our knowledge, this is the first demonstration of a quantitative relationship between the extent of structural damage to the CST and functional reorganization in stroke patients. This relationship was observed in stroke patients with heterogeneous lesions, suggesting that CST damage is a factor relevant to the variation in functional reorganization in the clinical population.

Dynamic changes in corticospinal tracts after stroke detected by fibretracking

BACKGROUND AND AIMS

The integrity of motor pathways and functional connectivity patterns are important in assessing plastic changes related to successful recovery, to obtain prognostic information and to monitor future therapeutic strategies of stroke patients. We tested the following hypotheses: (1) that changes in axonal integrity along the corticospinal tract after stroke can be detected as a reduction in fractional anisotropy; and (2) that sustained low fractional anisotropy is indicative of axonal loss and therefore is correlated with poor motor outcome, as measured by specific neurological motor scores.

METHODS

We developed a segmentation tool based on magnetic resonance diffusion tensor imaging in conjunction with three dimensional fibretracking for longitudinal studies of the corticospinal tract, and used specific neurological motor scores to test the hypotheses in five stroke patients within the first week and 30 and 90 days after the stroke.

RESULTS

Reduction in fractional anisotropy within the first weeks after stroke reflected a decline in axonal integrity, leading to Wallerian degeneration, and demonstrated a correlation between the temporal evolution of fractional anisotropy and motor function in patients with poor motor outcome.

CONCLUSION

The study demonstrated the feasibility of fibretracking as a segmentation tool for mapping distal parts of the corticospinal motor pathways and showed that fractional anisotropy in the segmented corticospinal tract is a sensitive measure of structural changes after stroke.

Diffusion Tensor Magnetic Resonance Imaging

Molecular diffusion plays an important role in many biologic phenomena. The ability to study diffusion, therefore, is extremely useful in physiology and medicine. MRI offers a non-invasive window to diffusion, particularly water self-diffusion. MRI techniques, which provide diffusion sensitivity or quantitation (diffusion tensor MRI [DTI]), have found widespread application in neuroscience and medicine, including the evaluation of stroke, brain development, tumor imaging, and demyelinating disorders. We discuss the tensor nature of diffusion and provide an overview of how DTI offers unique information on tissue organization, water mobility, and disease states, particularly those of neuro-ophthalmologic interest.

A method for obtaining tract-specific diffusion tensor MRI measurements in the presence of disease: application to patients with clinically isolated syndromes suggestive of multiple sclerosis

The aim of this study was to investigate whether neurological symptoms related to a specific axonal fiber tract in brain white matter were associated with a higher degree of tissue damage in that region, in patients at presentation with clinically isolated syndromes (CIS) suggestive of multiple sclerosis. To this end, a magnetic resonance imaging (MRI) method to segment and evaluate the fiber bundle of interest was implemented, taking care to circumvent the problems caused by pathology. Diffusion tensor (DT) MRI tractography was used to construct, from healthy volunteer data, a probability map for the pyramidal tract (PYT), and this map was applied to patients to calculate DT-derived metrics inside the PYT. In CIS patients with clinical symptoms related to motor function, the DT-derived mean diffusivity and the lesion volume in the PYT were found to be increased, while the fractional anisotropy was no different, when compared to those patients without motor symptoms. These results may be explained by several microstructural changes in the damaged tissue, such as changes in the permeability of axonal cell membranes, decreases of axonal density and edema. The approach taken to analyze a specific fiber tract was possible because the axons in the tract have a high orientational coherence, allowing tissue structure changes to be isolated from the tissue architecture. Its extension to other white matter fiber bundles is therefore limited to bundles with high orientational coherence.

Diffusion tensor imaging detects early Wallerian degeneration of the pyramidal tract after ischemic stroke

We used diffusion tensor imaging (DTI) to assess Wallerian degeneration of the pyramidal tract within the first 2 weeks after ischemic stroke, and correlated the extent of Wallerian degeneration with the motor deficit. Nine patients with middle cerebral artery stroke were examined 2-16 days after stroke by DTI and T2-weighted MRI. We measured fractional anisotropy (FA), averaged diffusivity (Dav), eigenvalues of the diffusion tensor and T2-weighted signal in the cerebral peduncle and compared these values between the affected and the unaffected side and between patients and six controls. FA was significantly reduced on the affected side compared to the unaffected side and compared to the control group. The largest eigenvalue was reduced, whereas the smallest eigenvalue was elevated on the affected side. There was no significant difference in T2-weighted signal and Dav. The decrease of anisotropy correlated positively with the motor deficit at the time of DTI study and 90 days after stroke. The reduction of anisotropy mirrors the disintegration of axonal structures, as it occurs in the early phase of Wallerian degeneration. DTI detects changes of water diffusion related to beginning pyramidal tract degeneration within the first 2 weeks after stroke that are not yet visible in conventional T2-weighted or orientationally averaged diffusion weighted MRI. We demonstrated for the first time a correlation of early DTI findings of pyramidal tract damage with the motor deficit. DTI can help prognosing recovery of motor function after stroke within the early subacute phase.

Functional imaging correlates of recovery after stroke in humans

The mechanisms that are responsible for the remarkable potential for functional recovery from stroke in humans remain unclear, and functional tomographic neuroimaging techniques increasingly are being used to investigate this issue. Such studies confirmed that recovery of function is related to the volume of penumbra tissue that escapes infarction. For language, reactivation of the primary functional areas in the dominant hemisphere is associated with the best prognosis. Evidence for functional plasticity in the immediate vicinity of infarcts, as demonstrated under experimental conditions with invasive methods, is still limited after stroke in humans, probably because of the limitations of spatial resolution of most currently available methods. Often, functional changes in the large-scale networks that support motor (for example, supplementary and premotor cortex) and language functions (for example, prefrontal cortex) have been found, more extensively after lesions acquired during childhood than at adult age. A frequent finding is an increase in the cerebral blood flow response in corresponding regions of the healthy hemisphere during unilateral motor activation or language activation. It is, however, not yet clear whether that is related to functional recovery, and there are several observations indicating that it is often inefficient. Further systematic follow-up studies and therapeutic intervention trials are needed to clarify these issues.

The persistent vegetative state after closed head injury: clinical and magnetic resonance imaging findings in 42 patients

OBJECT

In this retrospective study, the authors analyzed the frequency, anatomical distribution, and appearance of traumatic brain lesions in 42 patients in a posttraumatic persistent vegetative state.

METHODS

Cerebral magnetic resonance (MR) imaging was used to detect the number of lesions, which ranged from as few as five to as many as 19, with a mean of 11 lesions. In all 42 cases there was evidence on MR imaging of diffuse axonal injury, and injury to the corpus callosum was detected in all patients. The second most common area of diffuse axonal injury involved the dorsolateral aspect of the rostral brainstem (74% of patients). In addition, 65% of these patients exhibited white matter injury in the corona radiata and the frontal and temporal lobes. Lesions to the basal ganglia or thalamus were seen in 52% and 40% of patients, respectively. Magnetic resonance imaging showed some evidence of cortical contusion in 48% of patients in this study; the frontal and temporal lobes were most frequently involved. Injury to the parahippocampal gyrus was detected in 45% of patients; in this subgroup there was an 80% incidence of contralateral peduncular lesions in the midbrain. The most common pattern of injury (74% in this series) was the combination of focal lesions of the corpus callosum and the dorsolateral brainstem. In patients with no evidence of diffuse axonal injury in the upper brainstem (26% in this series), callosal lesions were most often associated with basal ganglia lesions. Lesions of the corona radiata and lobar white matter were equally distributed in patients with or without dorsolateral brainstem injury. Moreover, cortical contusions and thalamic, parahippocampal, and cerebral peduncular lesions were also similarly distributed in both groups.

CONCLUSIONS

The data indicate that diffuse axonal injury may be the major form of primary brain damage in the posttraumatic persistent vegetative state. In addition, the authors demonstrated in this study that MR imaging, in conjunction with a precise clinical correlation, may provide useful supportive information for the accurate diagnosis of a persistent vegetative state after traumatic brain injury.

MRI demonstration of Wallerian degeneration in various intracranial lesions and its clinical implications

Dynamic signal intensity changes of Wallerian degeneration (WD) are well documented in cases of stroke. These changes have been staged I-IV, depending on time-specific signal intensity changes in corticospinal tract with magnetic resonance imaging (MRI). We performed both prospective and retrospective evaluation of various intracranial lesions to look for evidence of WD and to assess its prognostic implications. Eighteen patients of acute stroke were studied prospectively. Their functional disability was evaluated by using a modified Barthel index of activity of daily living (ADL) at presentation, at 1 month and at 4 months, and was correlated with presence or absence of WD on MRI. 10/18 patients showed signal intensity changes of WD on MRI and their mean ADL score changed from 9.1 at 1 month to 11.4 at 4 months duration suggestive of moderate to severe disability after 4 months of stroke. The rest of the eight patients, where MRI did not reveal signal intensity changes of WD, the mean ADL score improved from 10.37 at 1 month to 17.5 at 4 months, suggesting significant improvement in their clinical disability. 520 patients were studied retrospectively, out of whom 31 showed signal intensity changes of WD in various intracranial lesions, i.e. infarcts (14/220), intracranial haematoma (4/147), arterio-venous malformation (1/20), tumour (6/98), multiple sclerosis (5/20) and encephalitis (1/15). Presence of WD in these intracranial lesions correlated well with persistent clinical disability. This observation has immense prognostic value, particularly in relapsing and remitting disease like multiple sclerosis. We conclude that WD can be seen secondary to any CNS insult with MRI and its presence correlates well with persistent functional disability. It thus has prognostic value.