Distribution of brain sodium accumulation correlates with disability in multiple sclerosis: a cross-sectional 23Na MR imaging study

Advanced Brain Imaging in Central Nervous System Demyelinating Diseases

In recent decades, advances in neuroimaging have profoundly transformed our comprehension of central nervous system demyelinating diseases. Remarkable technological progress has enabled the integration of cutting-edge acquisition and postprocessing techniques, proving instrumental in characterizing subtle focal changes, diffuse microstructural alterations, and macroscopic pathologic processes. This review delves into state-of-the-art modalities applied to multiple sclerosis, neuromyelitis optica spectrum disorders, and myelin oligodendrocyte glycoprotein antibody-associated disease. Furthermore, it explores how this dynamic landscape holds significant promise for the development of effective and personalized clinical management strategies, encompassing support for differential diagnosis, prognosis, monitoring treatment response, and patient stratification.

An update on the role of magnetic resonance imaging in predicting and monitoring multiple sclerosis progression

INTRODUCTION

While magnetic resonance imaging (MRI) is established in diagnosing and monitoring disease activity in multiple sclerosis (MS), its utility in predicting and monitoring disease progression is less clear.

AREAS COVERED

The authors consider changing concepts in the phenotypic classification of MS, including progression independent of relapses; pathological processes underpinning progression; advances in MRI measures to assess them; how well MRI features explain and predict clinical outcomes, including models that assess disease effects on neural networks, and the potential role for machine learning.

EXPERT OPINION

Relapsing-remitting and progressive MS have evolved from being viewed as mutually exclusive to having considerable overlap. Progression is likely the consequence of several pathological elements, each important in building more holistic prognostic models beyond conventional phenotypes. MRI is well placed to assess pathogenic processes underpinning progression, but we need to bridge the gap between MRI measures and clinical outcomes. Mapping pathological effects on specific neural networks may help and machine learning methods may be able to optimize predictive markers while identifying new, or previously overlooked, clinically relevant features. The ever-increasing ability to measure features on MRI raises the dilemma of what to measure and when, and the challenge of translating research methods into clinically useable tools.

Myopia, Sodium Chloride, and Vitreous Fluid Imbalance: A Nutritional Epidemiology Perspective

Theories of myopia etiology based on near work and lack of outdoor exposure have had inconsistent support and have not prevented the rising prevalence of global myopia. New scientific theories in the cause and prevention of myopia are needed. Myopia prevalence is low in native people consuming traditional diets lacking in sodium chloride, and nutritional epidemiological evidence supports the association of rising myopia prevalence with dietary sodium intake. East Asian populations have among the highest rates of myopia associated with high dietary sodium. Similar associations of sodium and rising myopia prevalence were observed in the United States in the late 20th century. The present perspective synthesizes nutritional epidemiology evidence with pathophysiological concepts and proposes that axial myopia occurs from increased fluid retention in the vitreous of the eye, induced by dietary sodium chloride intake. Salt disturbs ionic permeability of retinal membranes, increases the osmotic gradient flow of fluid into the vitreous, and stretches ocular tissue during axial elongation. Based on the present nutritional epidemiology evidence, experimental research should investigate the effect of sodium chloride as the cause of myopia, and clinical research should test a very low-salt diet in myopia correction and prevention.

Influence of Residual Quadrupolar Interaction on Quantitative Sodium Brain Magnetic Resonance Imaging of Patients With Multiple Sclerosis

OBJECTIVES

The purpose of this work was to evaluate the influence of residual quadrupolar interaction on the determination of human brain apparent tissue sodium concentrations (aTSCs) using quantitative sodium magnetic resonance imaging ( 23 Na MRI) in healthy controls (HCs) and patients with multiple sclerosis (MS). Especially, it was investigated if the more detailed examination of residual quadrupolar interaction effects enables further analysis of the observed 23 Na MRI signal increase in MS patients.

MATERIALS AND METHODS

23 Na MRI with a 7 T MR system was performed on 21 HC and 50 MS patients covering all MS subtypes (25 patients with relapsing-remitting MS, 14 patients with secondary progressive MS, and 11 patients with primary progressive MS) using 2 different 23 Na pulse sequences for quantification: a commonly used standard sequence (aTSC Std ) as well as a sequence with shorter excitation pulse length and lower flip angle for minimizing signal loss resulting from residual quadrupolar interactions (aTSC SP ). Apparent tissue sodium concentration was determined using the same postprocessing pipeline including correction of the receive profile of the radiofrequency coil, partial volume correction, and relaxation correction. Spin dynamic simulations of spin-3/2 nuclei were performed to aid in the understanding of the measurement results and to get deeper insight in the underlying mechanisms.

RESULTS

In normal-appearing white matter (NAWM) of HC and all MS subtypes, the aTSC SP values were approximately 20% higher than the aTSC Std values ( P < 0.001). In addition, the ratio aTSC SP /aTSC Std was significantly higher in NAWM than in normal-appearing gray matter (NAGM) for all subject cohorts ( P < 0.002). In NAWM, aTSC Std values were significantly higher in primary progressive MS compared with HC ( P = 0.01) as well as relapsing-remitting MS ( P = 0.03). However, in contrast, no significant differences between the subject cohorts were found for aTSC SP . Spin simulations assuming the occurrence of residual quadrupolar interaction in NAWM were in good accordance with the measurement results, in particular, the ratio aTSC SP /aTSC Std in NAWM and NAGM.

CONCLUSIONS

Our results showed that residual quadrupolar interactions in white matter regions of the human brain have an influence on aTSC quantification and therefore must be considered, especially in pathologies with expected microstructural changes such as loss of myelin in MS. Furthermore, the more detailed examination of residual quadrupolar interactions may lead to a better understanding of the pathologies themselves.

Sodium Dynamics in the Cellular Environment

Sodium ions are essential for the functions of biological cells, and they are maintained at the balance between intra- and extracellular environments. The quantitative assessment of intra- and extracellular sodium as well as its dynamics can provide crucial physiological information on a living system. ²³Na nuclear magnetic resonance (NMR) is a powerful and noninvasive technique to probe the local environment and dynamics of sodium ions. However, due to the complex relaxation behavior of the quadrupolar nucleus in the intermediate-motion regime and because of the heterogeneous compartments and diverse molecular interactions in the cellular environment, the understanding of the ²³Na NMR signal in biological systems is still at the early stage. In this work, we characterize the relaxation and diffusion of sodium ions in the solutions of proteins and polysaccharides, as well as in the in vitro samples of living cells. The multi-exponential behavior of ²³Na transverse relaxation has been analyzed according to the relaxation theory to derive the crucial information related to the ionic dynamics and molecular binding in the solutions. The bi-compartment model of transverse relaxation and diffusion measurements can corroborate each other to quantify the fractions of intra- and extracellular sodium. We show that ²³Na relaxation and diffusion can be used to monitor the viability of human cells, which offers versatile NMR metrics for in vivo studies.

Influence of image contrasts and reconstruction methods on the classification of multiple sclerosis-like lesions in simulated sodium magnetic resonance imaging

PURPOSE

To evaluate the classifiability of small multiple sclerosis (MS)-like lesions in simulated sodium (²³ Na) MRI for different ²³ Na MRI contrasts and reconstruction methods.

METHODS

²³ Na MRI and ²³ Na inversion recovery (IR) MRI of a phantom and simulated brain with and without lesions of different volumes (V = 1.3-38.2 nominal voxels) were simulated 100 times by adding Gaussian noise matching the SNR of real 3T measurements. Each simulation was reconstructed with four different reconstruction methods (Gridding without and with Hamming filter, Compressed sensing (CS) reconstruction without and with anatomical ¹ H prior information). Based on the mean signals within the lesion volumes of simulations with and without lesions, receiver operating characteristics (ROC) were determined and the area under the curve (AUC) was calculated to assess the classifiability for each lesion volume.

RESULTS

Lesions show higher classifiability in ²³ Na MRI than in ²³ Na IR MRI. For typical parameters and SNR of a 3T scan, the voxel normed minimal classifiable lesion volume (AUC > 0.9) is 2.8 voxels for ²³ Na MRI and 19 voxels for ²³ Na IR MRI, respectively. In terms of classifiability, Gridding with Hamming filter and CS without anatomical ¹ H prior outperform CS reconstruction with anatomical ¹ H prior.

CONCLUSION

Reliability of lesion classifiability strongly depends on the lesion volume and the ²³ Na MRI contrast. Additional incorporation of ¹ H prior information in the CS reconstruction was not beneficial for the classification of small MS-like lesions in ²³ Na MRI.

Variability by region and method in human brain sodium concentrations estimated by 23Na magnetic resonance imaging: a meta-analysis

Sodium imaging (²³Na-MRI) is of interest in neurological conditions given potential sensitivity to the physiological and metabolic status of tissues. Benchmarks have so far been restricted to parenchyma or grey/white matter (GM/WM). We investigate (1) the availability of evidence, (2) regional pooled estimates and (3) variability attributable to region/methodology. MEDLINE literature search for tissue sodium concentration (TSC) measured in specified 'healthy' brain regions returned 127 reports, plus 278 retrieved from bibliographies. 28 studies met inclusion criteria, including 400 individuals. Reporting variability led to nested data structure, so we used multilevel meta-analysis and a random effects model to pool effect sizes. The pooled mean from 141 TSC estimates was 40.51 mM (95% CI 37.59-43.44; p < 0.001, I²_Total=99.4%). Tissue as a moderator was significant (F²₁₄ = 65.34, p-val < .01). Six sub-regional pooled means with requisite statistical power were derived. We were unable to consider most methodological and demographic factors sought because of non-reporting, but each factor included beyond tissue improved model fit. Significant residual heterogeneity remained. The current estimates provide an empirical point of departure for better understanding in ²³Na-MRI. Improving on current estimates supports: (1) larger, more representative data collection/sharing, including (2) regional data, and (3) agreement on full reporting standards.

Quantitative 7T sodium magnetic resonance imaging of the human brain using a 32-channel phased-array head coil: Application to patients with secondary progressive multiple sclerosis

Apparent tissue sodium concentrations (aTSCs) determined by ²³ Na brain magnetic resonance imaging (MRI) have the potential to serve as a biomarker in pathologies such as multiple sclerosis (MS). However, the quantification is hindered by the intrinsically low signal-to-noise ratio of ²³ Na MRI. The purpose of this study was to improve the accuracy and reliability of quantitative ²³ Na brain MRI by implementing a dedicated postprocessing pipeline and to evaluate the applicability of the developed approach for the examination of MS patients. ²³ Na brain MRI measurements of 13 healthy volunteers and 17 patients with secondary progressive multiple sclerosis (SPMS) were performed at 7 T using a dual-tuned ²³ Na/¹ H birdcage coil with a receive-only 32-channel phased array. The aTSC values were determined for normal appearing white matter (NAWM) and normal appearing gray matter (NAGM) in healthy subjects and SPMS patients. Signal intensities were normalized using the mean cerebrospinal fluid (CSF) sodium concentration determined in 37 separate patients receiving a spinal tap for routine diagnostic purposes. Five volunteers underwent MRI examinations three times in a row to assess repeatability. Coefficients of variation (CoVs) were used to quantify the repeatability of the proposed method. aTSC values were compared regarding brain regions and subject cohort using the paired-samples Wilcoxon rank-sum test. Laboratory CSF sodium concentration did not differ significantly between patients without and with MS (p = 0.42). The proposed quantification workflow for ²³ Na MRI was highly repeatable with CoVs averaged over all five volunteers of 1.9% ± 0.9% for NAWM and 2.2% ± 1.6% for NAGM. Average NAWM aTSC was significantly higher in patients with SPMS compared with the control group (p = 0.009). Average NAGM aTSC did not differ significantly between healthy volunteers and MS patients (p = 0.98). The proposed postprocessing pipeline shows high repeatability and the results can serve as a baseline for further studies establishing ²³ Na brain MRI as a biomarker in diseases such as MS.

A uniformity correction method to reduce scan time for 7T sodium imaging of brain tumors

BACKGROUND AND PURPOSE

Sodium imaging shows great potential for the characterization of brain tumors. Intensity correction is required but the additional scan time is costly. Recent developments can halve the time but were optimized in normal brains and may not be applicable in brain tumor imaging. We aim to develop an individualized uniformity correction for sodium imaging optimized for brain tumor patients that reduces scan time but provides high-resolution images for clinical practice.

METHODS

Two-, 4-, and 6-mm iso-cubic voxel resolution birdcage coil images were used to calculate the 2-mm iso-cubic voxel individual sensitivity maps in healthy subjects (n = 3). Cut profiles were compared to determine the optimal approach. In addition, a 3-dimensional phantom was developed to test a generalized uniformity correction approach in both healthy subjects (n = 3) and tumor patients (n = 3).

RESULTS

The cut profiles showed that the average correlation coefficient between 2- and 4-mm birdcage image correction results was r = .9937, and r = .9876 for 2- and 6-mm birdcage images. The correlation result between individual map correction and phantom map correction was r = .9817.

CONCLUSION

The 4 mm birdcage coil image provided the optimal approach for both as a compromise between the time-savings effect and image quality. This method allows for a 2-mm iso-cubic voxel resolution clinical sodium scan within 12 minutes. We also presented prescanned phantom sensitivity map results, which were designed to cover all patient head sizes. This approach provides an alternative solution in more time-sensitive cases.

Combining sodium MRI, proton MR spectroscopic imaging, and intracerebral EEG in epilepsy

Whole brain ionic and metabolic imaging has potential as a powerful tool for the characterization of brain diseases. We combined sodium MRI (²³ Na MRI) and ¹ H-MR Spectroscopic Imaging (¹ H-MRSI), assessing changes within epileptogenic networks in comparison with electrophysiologically normal networks as defined by stereotactic EEG (SEEG) recordings analysis. We applied a multi-echo density adapted 3D projection reconstruction pulse sequence at 7 T (²³ Na-MRI) and a 3D echo-planar spectroscopic imaging sequence at 3 T (¹ H-MRSI) in 19 patients suffering from drug-resistant focal epilepsy who underwent presurgical SEEG. We investigated ²³ Na MRI parameters including total sodium concentration (TSC) and the sodium signal fraction associated with the short component of T₂ * decay (f), alongside the level of metabolites N-acetyl aspartate (NAA), choline compounds (Cho), and total creatine (tCr). All measures were extracted from spherical regions of interest (ROIs) centered between two adjacent SEEG electrode contacts and z-scored against the same ROI in controls. Group comparison showed a significant increase in f only in the epileptogenic zone (EZ) compared to controls and compared to patients' propagation zone (PZ) and non-involved zone (NIZ). TSC was significantly increased in all patients' regions compared to controls. Conversely, NAA levels were significantly lower in patients compared to controls, and lower in the EZ compared to PZ and NIZ. Multiple regression analyzing the relationship between sodium and metabolites levels revealed significant relations in PZ and in NIZ but not in EZ. Our results are in agreement with the energetic failure hypothesis in epileptic regions associated with widespread tissue reorganization.

Grey-matter sodium concentration as an individual marker of multiple sclerosis severity

OBJECTIVE

Quantification of brain injury in patients with variable disability despite similar disease duration may be relevant to identify the mechanisms underlying disability in multiple sclerosis (MS). We aimed to compare grey-matter sodium abnormalities (GMSAs), a parameter reflecting neuronal and astrocyte dysfunction, in MS patients with benign multiple sclerosis (BMS) and non-benign multiple sclerosis (NBMS).

METHODS

We identified never-treated BMS patients in our local MS database of 1352 patients. A group with NBMS was identified with same disease duration. All participants underwent ²³Na magnetic resonance imaging (MRI). The existence of GMSA was detected by statistical analysis.

RESULTS

In total, 102 individuals were included (21 BMS, 25 NBMS and 56 controls). GMSA was detected in 10 BMS and 19 NBMS (11/16 relapsing-remitting multiple sclerosis (RRMS) and 8/9 secondary progressive multiple sclerosis (SPMS) patients) (p = 0.05). On logistic regression including the presence or absence of GMSA, thalamic volume, cortical grey-matter volume and T2-weighted lesion load, thalamic volume was independently associated with BMS status (odds ratio (OR) = 0.64 for each unit). Nonetheless, the absence of GMSA was independently associated when excluding patients with significant cognitive alteration (n = 7) from the BMS group (OR = 4.6).

CONCLUSION

Detection of GMSA in individuals and thalamic volume are promising to differentiate BMS from NBMS as compared with cortical or whole grey-matter atrophy and T2-weighted lesions.

Opportunities for Molecular Imaging in Multiple Sclerosis Management: Linking Probe to Treatment

Imaging has been a critical component of multiple sclerosis (MS) management for nearly 40 years. The visual information derived from structural MRI, that is, signs of blood-brain barrier disruption, inflammation and demyelination, and brain and spinal cord atrophy, are the primary metrics used to evaluate therapeutic efficacy in MS. The development of targeted imaging probes has expanded our ability to evaluate and monitor MS and its therapies at the molecular level. Most molecular imaging probes evaluated for MS applications are small molecules initially developed for PET, nearly half of which are derived from U.S. Food and Drug Administration-approved drugs and those currently undergoing clinical trials. Superparamagnetic and fluorinated particles have been used for tracking circulating immune cells (in situ labeling) and immunosuppressive or remyelinating therapeutic stem cells (ex vivo labeling) clinically using proton (hydrogen 1 [¹H]) and preclinically using fluorine 19 MRI. Translocator protein PET and ¹H MR spectroscopy have been demonstrated to complement imaging metrics from structural (gadolinium-enhanced) MRI in nine and six trials for MS disease-modifying therapies, respectively. Still, despite multiple demonstrations of the utility of molecular imaging probes to evaluate the target location and to elucidate the mechanisms of disease-modifying therapies for MS applications, their use has been sparse in both preclinical and clinical settings.

Increased brain tissue sodium concentration in Friedreich ataxia: A multimodal MR imaging study

In patients with Friedreich ataxia, structural MRI is typically used to detect abnormalities primarily in the brainstem, cerebellum, and spinal cord. The aim of the present study was to additionally investigate possible metabolic changes in Friedreich ataxia using in vivo sodium MRI that may precede macroanatomical alterations, and to explore potential associations with clinical parameters of disease progression. Tissue sodium concentration across the whole brain was estimated from sodium MRI maps acquired at 3 T and compared between 24 patients with Friedreich ataxia (21-57 years old, 13 females) and 23 controls (21-60 years old, 12 females). Tensor-based morphometry was used to assess volumetric changes. Total sodium concentrations and volumetric data in brainstem and cerebellum were correlated with clinical parameters, such as severity of ataxia, activity of daily living and disability stage, age, age at onset, and disease duration. Compared to controls, patients showed reduced brain volume in the right cerebellar lobules I-V (difference in means: -0.039% of total intracranial volume [TICV]; Cohen's d = 0.83), cerebellar white matter (WM) (-0.105%TICV; d = 1.16), and brainstem (-0.167%TICV; d = 1.22), including pons (-0.102%TICV; d = 1.00), medulla (-0.036%TICV; d = 1.72), and midbrain (-0.028%TICV; d = 1.05). Increased sodium concentration was additionally detected in the total cerebellum (difference in means: 2.865 mmol; d = 0.68), and in several subregions with highest effect sizes in left (5.284 mmol; d = 1.01) and right cerebellar lobules I-V (5.456 mmol; d = 1.00), followed by increases in the vermis (4.261 mmol; d = 0.72), and in left (2.988 mmol; d = 0.67) and right lobules VI-VII (2.816 mmol; d = 0.68). In addition, sodium increases were also detected in all brainstem areas (3.807 mmol; d = 0.71 to 5.42 mmol; d = 1.19). After controlling for age, elevated total sodium concentrations in right cerebellar lobules IV were associated with younger age at onset (r = -0.43) and accordingly with longer disease duration in patients (r = 0.43). Our findings support the potential of in vivo sodium MRI to detect metabolic changes of increased total sodium concentration in the cerebellum and brainstem, the key regions in Friedreich ataxia. In addition to structural changes, sodium changes were present in cerebellar hemispheres and vermis without concomitant significant atrophy. Given the association with age at disease onset or disease duration, metabolic changes should be further investigated longitudinally and in larger cohorts of early disease stages to determine the usefulness of sodium MRI as a biomarker for early neuropathological changes in Friedreich ataxia and efficacy measure for future clinical trials.

Comprehensive Account of Sodium Imaging and Spectroscopy for Brain Research

Sodium (²³Na) is a vital component of neuronal cells and plays a key role in various signal transmission processes. Hence, information on sodium distribution in the brain using magnetic resonance imaging (MRI) provides useful information on neuronal health. ²³Na MRI and MR spectroscopy (MRS) improve the diagnosis, prognosis, and clinical monitoring of neurological diseases but confront some inherent limitations that lead to low signal-to-noise ratio, longer scan time, and diminished partial volume effects. Recent advancements in multinuclear MR technology have helped in further exploration in this domain. We aim to provide a comprehensive description of ²³Na MRI and MRS for brain research including the following aspects: (a) theoretical background for understanding ²³Na MRI and MRS fundamentals; (b) technological advancements of ²³Na MRI with respect to pulse sequences, RF coils, and sodium compartmentalization; (c) applications of ²³Na MRI in the early diagnosis and prognosis of various neurological disorders; (d) structural-chronological evolution of sodium spectroscopy in terms of its numerous applications in human studies; (e) the data-processing tools utilized in the quantitation of sodium in the respective anatomical regions.

The Role of Molecular Imaging as a Marker of Remyelination and Repair in Multiple Sclerosis

The appearance of new disease-modifying therapies in multiple sclerosis (MS) has revolutionized our ability to fight inflammatory relapses and has immensely improved patients’ quality of life. Although remarkable, this achievement has not carried over into reducing long-term disability. In MS, clinical disability progression can continue relentlessly irrespective of acute inflammation. This “silent” disease progression is the main contributor to long-term clinical disability in MS and results from chronic inflammation, neurodegeneration, and repair failure. Investigating silent disease progression and its underlying mechanisms is a challenge. Standard MRI excels in depicting acute inflammation but lacks the pathophysiological lens required for a more targeted exploration of molecular-based processes. Novel modalities that utilize nuclear magnetic resonance’s ability to display in vivo information on imaging look to bridge this gap. Displaying the CNS through a molecular prism is becoming an undeniable reality. This review will focus on “molecular imaging biomarkers” of disease progression, modalities that can harmoniously depict anatomy and pathophysiology, making them attractive candidates to become the first valid biomarkers of neuroprotection and remyelination.

Compressed Sensing in Sodium Magnetic Resonance Imaging: Techniques, Applications, and Future Prospects

Sodium (²³ Na) yields the second strongest nuclear magnetic resonance (NMR) signal in biological tissues and plays a vital role in cell physiology. Sodium magnetic resonance imaging (MRI) can provide insights into cell integrity and tissue viability relative to pathologies without significant anatomical alternations, and thus it is considered to be a potential surrogate biomarker that provides complementary information for standard hydrogen (¹ H) MRI in a noninvasive and quantitative manner. However, sodium MRI suffers from a relatively low signal-to-noise ratio and long acquisition times due to its relatively low NMR sensitivity. Compressed sensing-based (CS-based) methods have been shown to accelerate sodium imaging and/or improve sodium image quality significantly. In this manuscript, the basic concepts of CS and how CS might be applied to improve sodium MRI are described, and the historical milestones of CS-based sodium MRI are briefly presented. Representative advanced techniques and evaluation methods are discussed in detail, followed by an expose of clinical applications in multiple anatomical regions and diseases as well as thoughts and suggestions on potential future research prospects of CS in sodium MRI. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 1.

Diffusely abnormal white matter in multiple sclerosis

MRI enables detailed in vivo depiction of multiple sclerosis (MS) pathology. Localized areas of MS damage, commonly referred to as lesions, or plaques, have been a focus of clinical and research MRI studies for over four decades. A nonplaque MRI abnormality which is present in at least 25% of MS patients but has received far less attention is diffusely abnormal white matter (DAWM). DAWM has poorly defined boundaries and a signal intensity that is between normal-appearing white matter and classic lesions on proton density and T₂ -weighted images. All clinical phenotypes of MS demonstrate DAWM, including clinically isolated syndrome, where DAWM is associated with higher lesion volume, reduced brain volume, and earlier conversion to MS. Advanced MRI metric abnormalities in DAWM tend to be greater than those in NAWM, but not as severe as focal lesions, with myelin, axons, and water-related changes commonly reported. Histological studies demonstrate a primary lipid abnormality in DAWM, with some axonal damage and lesser involvement of myelin proteins. This review provides an overview of DAWM identification, summarizes in vivo and postmortem observations, and comments on potential pathophysiological mechanisms, which may underlie DAWM in MS. Given the prevalence and potential clinical impact of DAWM, the number of imaging studies focusing on DAWM is insufficient. Characterization of DAWM significance and microstructure would benefit from larger longitudinal and additional quantitative imaging efforts. Revisiting data from previous studies that included proton density and T₂ imaging would enable retrospective DAWM identification and analysis.

7 Tesla and Beyond: Advanced Methods and Clinical Applications in Magnetic Resonance Imaging

ABSTRACT

Ultrahigh magnetic fields offer significantly higher signal-to-noise ratio, and several magnetic resonance applications additionally benefit from a higher contrast-to-noise ratio, with static magnetic field strengths of B0 ≥ 7 T currently being referred to as ultrahigh fields (UHFs). The advantages of UHF can be used to resolve structures more precisely or to visualize physiological/pathophysiological effects that would be difficult or even impossible to detect at lower field strengths. However, with these advantages also come challenges, such as inhomogeneities applying standard radiofrequency excitation techniques, higher energy deposition in the human body, and enhanced B0 field inhomogeneities. The advantages but also the challenges of UHF as well as promising advanced methodological developments and clinical applications that particularly benefit from UHF are discussed in this review article.

Exposure to 16 h of normobaric hypoxia induces ionic edema in the healthy brain

Following prolonged exposure to hypoxic conditions, for example, due to ascent to high altitude, stroke, or traumatic brain injury, cerebral edema can develop. The exact nature and genesis of hypoxia-induced edema in healthy individuals remain unresolved. We examined the effects of prolonged, normobaric hypoxia, induced by 16 h of exposure to simulated high altitude, on healthy brains using proton, dynamic contrast enhanced, and sodium MRI. This dual approach allowed us to directly measure key factors in the development of hypoxia-induced brain edema: (1) Sodium signals as a surrogate of the distribution of electrolytes within the cerebral tissue and (2) K^trans as a marker of blood–brain–barrier integrity. The measurements point toward an accumulation of sodium ions in extra- but not in intracellular space in combination with an intact endothelium. Both findings in combination are indicative of ionic extracellular edema, a subtype of cerebral edema that was only recently specified as an intermittent, yet distinct stage between cytotoxic and vasogenic edemas. In sum, here a combination of imaging techniques demonstrates the development of ionic edemas following prolonged normobaric hypoxia in agreement with cascadic models of edema formation.

Prolonged hypoxia, which can be due to stroke or ascent to high altitude, can lead to cerebral edema. Here, the authors used a combination of sodium and proton MRI and experimentally induced hypoxic conditions to identify the cause for brain swelling: Ionic edema, an intermediate between cytotoxic and vasogenic edema defined by sodium ion accumulation in extracellular space and an intact endothelium.

Potential Biomarkers Associated with Multiple Sclerosis Pathology

Multiple sclerosis (MS) is a complex disease of the central nervous system (CNS) that involves an intricate and aberrant interaction of immune cells leading to inflammation, demyelination, and neurodegeneration. Due to the heterogeneity of clinical subtypes, their diagnosis becomes challenging and the best treatment cannot be easily provided to patients. Biomarkers have been used to simplify the diagnosis and prognosis of MS, as well as to evaluate the results of clinical treatments. In recent years, research on biomarkers has advanced rapidly due to their ability to be easily and promptly measured, their specificity, and their reproducibility. Biomarkers are classified into several categories depending on whether they address personal or predictive susceptibility, diagnosis, prognosis, disease activity, or response to treatment in different clinical courses of MS. The identified members indicate a variety of pathological processes of MS, such as neuroaxonal damage, gliosis, demyelination, progression of disability, and remyelination, among others. The present review analyzes biomarkers in cerebrospinal fluid (CSF) and blood serum, the most promising imaging biomarkers used in clinical practice. Furthermore, it aims to shed light on the criteria and challenges that a biomarker must face to be considered as a standard in daily clinical practice.

Sodium Intensity Changes Differ Between Relaxation- and Density-Weighted MRI in Multiple Sclerosis

Introduction: The source of Tissue Sodium Concentration (TSC) increase in Multiple Sclerosis (MS) remains unclear, and could be attributed to altered intracellular sodium concentration or tissue microstructure. This paper investigates sodium in MS using three new MRI sequences. Methods: Three sodium scans were acquired at 4.7 T from 30 patients (11 relapsing-remitting, 10 secondary-progressive, 9 primary-progressive) and 9 healthy controls including: Density-Weighted (NaDW), with very short 30° excitation for more accurate TSC measurement; Projection Acquisition with Coherent MAgNetization (NaPACMAN), designed for enhanced relaxation-based contrast; and Soft Inversion Recovery FLuid Attenuation (NaSIRFLA), developed to reduce fluid space contribution. Signal was measured in both lesions (n = 397) and normal appearing white matter (NAWM) relative to controls in the splenium of corpus callosum and the anterior and posterior limbs of internal capsule. Correlations with clinical and cognitive evaluations were tested over all MS patients. Results: Sodium intensity in MS lesions was elevated over control WM by a greater amount for NaPACMAN (75%) than NaDW (35%), the latter representing TSC. In contrast, NaSIRFLA exhibited lower intensity, but only for region specific analysis in the SCC (-7%). Sodium intensity in average MS NAWM was not significantly different than control WM for either of the three scans. NaSIRFLA in the average NAWM and specifically the posterior limb of internal capsules positively correlated with the Paced Auditory Serial Addition Test (PASAT). Discussion: Lower NaSIRFLA signal in lesions and ~2× greater NaPACMAN signal elevation over control WM than NaDW can be explained with a demyelination model that also includes edema. A NAWM demyelination model that includes tissue atrophy suggests no signal change for NaSIRFLA, and only slightly greater NAWM signal than control WM for both NaDW and NaPACMAN, reflecting experimental results. Models were derived from previous total and myelin water fraction study in MS with T2-relaxometry, and for the first time include sodium within the myelin water space. Reduced auditory processing association with lower signal on NaSIRFLA cannot be explained by greater demyelination and its modeled impact on the three sodium MRI sequences. Alternative explanations include intra- or extracellular sodium concentration change. Relaxation-weighted sodium MRI in combination with sodium-density MRI may help elucidate microstructural and metabolic changes in MS.

Longitudinal Sodium MRI of Multiple Sclerosis Lesions: Is there Added Value of Sodium Inversion Recovery MRI

BACKGROUND

Sodium enhancement has been demonstrated in multiple sclerosis (MS) lesions.

PURPOSE

To investigate sodium MRI with and without an inversion recovery pulse in acute MS lesions in an MS relapse and during recovery.

STUDY TYPE

Prospective.

SUBJECTS

Twenty-nine relapsing-remitting MS patients with an acute relapse were included.

FIELD STRENGTH/SEQUENCE

A 3D density-adapted radial sodium sequence at 3 T using a dual-tuned (²³ Na/¹ H) head coil.

ASSESSMENT

Full-brain images of the tissue sodium concentration (TSC1, n = 29) and a sodium inversion recovery sequence (SIR1, n = 20) at the beginning of the anti-inflammatory therapy and on medium-term follow-up visits (days 27-99, n = 12 [TSC], n = 5 [SIR]) were measured. Regions of interest (RoIs) with contrast enhancement (T₁ CE+) and without change in T1-weighted imaging (FL + T1n) were normalized (nTSC and nSIR). To gain insight on the origin of the TSC enhancement at time point 1, it is investigated whether the nTSC enhancement of the lesions is accompanied by a change of the respective nSIR. Potential prognostic value of nSIR1 is examined referring to the nTSC progression. STATISTICAL TESTS: nTSC and nSIR were compared regarding the type of lesion and the time point using a one-way ANOVA. Pearson's correlation coefficient was calculated for nTSC over nSIR and for nTSC1-nTSC2 over nSIR1. A P-value <0.05 was considered statistically significant.

RESULTS

At the first measurement, all lesion types showed increased nTSC, while nSIR was decreased in the FL + T₁ n and the T₁ CE+ lesions in comparison to the normal-appearing white matter. For acute lesions, the difference between nTSC at baseline and nTSC at time point 2 showed a significant correlation with the baseline nSIR.

DATA CONCLUSION

At time point 1, nTSC is increased, while nSIR is unchanged or decreased in the lesions. The mean sodium IR signal at baseline correlates with recovery or progression of an acute lesion.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 4.

Skin sodium is increased in male patients with multiple sclerosis and related animal models

Novel MRI techniques allow a noninvasive quantification of tissue sodium and reveal the skin as a prominent compartment of sodium storage in health and disease. Since multiple sclerosis (MS) immunopathology is initiated in the periphery and increased sodium concentrations induce proinflammatory immune cells, the skin represents a promising compartment linking high sodium concentrations and MS immunopathology. We used a 7-T sodium MRI (23Na-MRI) and inductively coupled plasma mass spectrometry to investigate the skin sodium content in two mouse models of MS. We additionally performed 3-T 23Na-MRI of calf skin and muscles in 29 male relapsing-remitting MS (RRMS) patients and 29 matched healthy controls. Demographic and clinical information was collected from interviews, and disease activity was assessed by expanded disability status scale scoring. 23Na-MRI and chemical analysis demonstrated a significantly increased sodium content in the skin during experimental autoimmune encephalomyelitis independent of active immunization. In male patients with RRMS, 23Na-MRI demonstrated a higher sodium signal in the area of the skin compared to age- and biological sex-matched healthy controls with higher sodium, predicting future disease activity in cranial MRI. In both studies, the sodium enrichment was specific to the skin, as we found no alterations of sodium signals in the muscle or other tissues. Our data add to the recently identified importance of the skin as a storage compartment of sodium and may further represent an important organ for future investigations on salt as a proinflammatory agent driving autoimmune neuroinflammation such as that in MS.

Multiparametric MRI for Characterization of the Basal Ganglia and the Midbrain

Objectives To characterize subcortical nuclei by multi-parametric quantitative magnetic resonance imaging.

Materials and Methods: The following quantitative multiparametric MR data of five healthy volunteers were acquired on a 7T MRI system: 3D gradient echo (GRE) data for the calculation of quantitative susceptibility maps (QSM), GRE sequences with and without off-resonant magnetic transfer pulse for magnetization transfer ratio (MTR) calculation, a magnetization−prepared 2 rapid acquisition gradient echo sequence for T₁ mapping, and (after a coil change) a density-adapted 3D radial pulse sequence for ²³Na imaging. First, all data were co-registered to the GRE data, volumes of interest (VOIs) for 21 subcortical structures were drawn manually for each volunteer, and a combined voxel-wise analysis of the four MR contrasts (QSM, MTR, T₁, ²³Na) in each structure was conducted to assess the quantitative, MR value-based differentiability of structures. Second, a machine learning algorithm based on random forests was trained to automatically classify the groups of multi-parametric voxel values from each VOI according to their association to one of the 21 subcortical structures.

Results The analysis of the integrated multimodal visualization of quantitative MR values in each structure yielded a successful classification among nuclei of the ascending reticular activation system (ARAS), the limbic system and the extrapyramidal system, while classification among (epi-)thalamic nuclei was less successful. The machine learning-based approach facilitated quantitative MR value-based structure classification especially in the group of extrapyramidal nuclei and reached an overall accuracy of 85% regarding all selected nuclei.

Conclusion Multimodal quantitative MR enabled excellent differentiation of a wide spectrum of subcortical nuclei with reasonable accuracy and may thus enable sensitive detection of disease and nucleus-specific MR-based contrast alterations in the future.

Brain microstructural and metabolic alterations detected in vivo at onset of the first demyelinating event

In early multiple sclerosis, a clearer understanding of normal-brain tissue microstructural and metabolic abnormalities will provide valuable insights into its pathophysiology. We used multi-parametric quantitative MRI to detect alterations in brain tissues of patients with their first demyelinating episode. We acquired neurite orientation dispersion and density imaging [to investigate morphology of neurites (dendrites and axons)] and ²³Na MRI (to estimate total sodium concentration, a reflection of underlying changes in metabolic function). In this cross-sectional study, we enrolled 42 patients diagnosed with clinically isolated syndrome or multiple sclerosis within 3 months of their first demyelinating event and 16 healthy controls. Physical and cognitive scales were assessed. At 3 T, we acquired brain and spinal cord structural scans, and neurite orientation dispersion and density imaging. Thirty-two patients and 13 healthy controls also underwent brain ²³Na MRI. We measured neurite density and orientation dispersion indices and total sodium concentration in brain normal-appearing white matter, white matter lesions, and grey matter. We used linear regression models (adjusting for brain parenchymal fraction and lesion load) and Spearman correlation tests (significance level P ≤ 0.01). Patients showed higher orientation dispersion index in normal-appearing white matter, including the corpus callosum, where they also showed lower neurite density index and higher total sodium concentration, compared with healthy controls. In grey matter, compared with healthy controls, patients demonstrated: lower orientation dispersion index in frontal, parietal and temporal cortices; lower neurite density index in parietal, temporal and occipital cortices; and higher total sodium concentration in limbic and frontal cortices. Brain volumes did not differ between patients and controls. In patients, higher orientation dispersion index in corpus callosum was associated with worse performance on timed walk test (P = 0.009, B = 0.01, 99% confidence interval = 0.0001 to 0.02), independent of brain and lesion volumes. Higher total sodium concentration in left frontal middle gyrus was associated with higher disability on Expanded Disability Status Scale (r_s = 0.5, P = 0.005). Increased axonal dispersion was found in normal-appearing white matter, particularly corpus callosum, where there was also axonal degeneration and total sodium accumulation. The association between increased axonal dispersion in the corpus callosum and worse walking performance implies that morphological and metabolic alterations in this structure could mechanistically contribute to disability in multiple sclerosis. As brain volumes were neither altered nor related to disability in patients, our findings suggest that these two advanced MRI techniques are more sensitive at detecting clinically relevant pathology in early multiple sclerosis.

Neuroimaging Correlates of Cognitive Dysfunction in Adults with Multiple Sclerosis

Cognitive impairment is a frequent and meaningful symptom in multiple sclerosis (MS), caused by the accrual of brain structural damage only partially counteracted by effective functional reorganization. As both these aspects can be successfully investigated through the application of advanced neuroimaging, here, we offer an up-to-date overview of the latest findings on structural, functional and metabolic correlates of cognitive impairment in adults with MS, focusing on the mechanisms sustaining damage accrual and on the identification of useful imaging markers of cognitive decline.

Statistical parametric mapping of three-dimensional local activity distribution of skeletal muscle using magnetic resonance imaging (MRI)

Analysis of the internal local activity distribution in human skeletal muscles is important for managing muscle fatigue/pain and dysfunction. However, no method is established for three-dimensional (3D) statistical analysis of features of activity regions common to multiple subjects during voluntary motor tasks. We investigated the characteristics of muscle activity distribution from the data of ten healthy subjects (29 ± 1 year old, 2 women) during voluntary teeth clenching under two different occlusal conditions by applying spatial normalization and statistical parametric mapping (SPM) to analysis of muscle functional magnetic resonance imaging (mfMRI) using increase in transverse relaxation time (T2) of the skeletal muscle induced by exercise. The expansion of areas with significant T2 increase was observed in the masticatory muscles after clenching with molar loss comparing with intact dentition. The muscle activity distribution characteristics common to a group of subjects, i.e., the active region in the temporal muscle ipsilateral to the side with the molar loss and medial pterygoid muscle contralateral to the side with the molar loss, were clarified in 3D by applying spatial normalization and SPM to mfMRI analysis. This method might elucidate the functional distribution within the muscles and the localized muscular activity related to skeletal muscle disorders.

Compressed sensing and the use of phased array coils in 23Na MRI: a comparison of a SENSE-based and an individually combined multi-channel reconstruction

PURPOSE

To implement and to evaluate a compressed sensing (CS) reconstruction algorithm based on the sensitivity encoding (SENSE) combination scheme (CS-SENSE), used to reconstruct sodium magnetic resonance imaging (23Na MRI) multi-channel breast data sets.

METHODS

In a simulation study, the CS-SENSE algorithm was tested and optimized by evaluating the structural similarity (SSIM) and the normalized root-mean-square error (NRMSE) for different regularizations and different undersampling factors (USF=1.8/3.6/7.2/14.4). Subsequently, the algorithm was applied to data from in vivo measurements of the healthy female breast (n=3) acquired at 7T. Moreover, the proposed CS-SENSE algorithm was compared to a previously published CS algorithm (CS-IND).

RESULTS

The CS-SENSE reconstruction leads to an increased image quality for all undersampling factors and employed regularizations. Especially if a simple 2nd order total variation is chosen as sparsity transformation, the CS-SENSE reconstruction increases the image quality of highly undersampled data sets (CS-SENSE: SSIMUSF=7.2=0.234, NRMSEUSF=7.2=0.491 vs. CS-IND: SSIMUSF=7.2=0.201, NRMSEUSF=7.2=0.506).

CONCLUSION

The CS-SENSE reconstruction supersedes the need of CS weighting factors for each channel as well as a method to combine single channel data. The CS-SENSE algorithm can be used to reconstruct undersampled data sets with increased image quality. This can be exploited to reduce total acquisition times in 23Na MRI.

Voxel-wise partial volume correction method for accurate estimation of tissue sodium concentration in 23 Na-MRI at 7 T

Sodium is crucial for the maintenance of cell physiology, and its regulation of the sodium-potassium pump has implications for various neurological conditions. The distribution of sodium concentrations in tissue can be quantitatively evaluated by means of sodium MRI (²³ Na-MRI). Despite its usefulness in diagnosing particular disease conditions, tissue sodium concentration (TSC) estimated from ²³ Na-MRI can be strongly biased by partial volume effects (PVEs) that are induced by broad point spread functions (PSFs) as well as tissue fraction effects. In this work, we aimed to propose a robust voxel-wise partial volume correction (PVC) method for ²³ Na-MRI. The method is based on a linear regression (LR) approach to correct for tissue fraction effects, but it utilizes a 3D kernel combined with a modified least trimmed square (3D-mLTS) method in order to minimize regression-induced inherent smoothing effects. We acquired ²³ Na-MRI data with conventional Cartesian sampling at 7 T, and spill-over effects due to the PSF were considered prior to correcting for tissue fraction effects using 3D-mLTS. In the simulation, we found that the TSCs of gray matter (GM) and white matter (WM) were underestimated by 20% and 11% respectively without correcting tissue fraction effects, but the differences between ground truth and PVE-corrected data after the PVC using the 3D-mLTS method were only approximately 0.6% and 0.4% for GM and WM, respectively. The capability of the 3D-mLTS method was further demonstrated with in vivo ²³ Na-MRI data, showing significantly lower regression errors (ie root mean squared error) as compared with conventional LR methods (p < 0.001). The results of simulation and in vivo experiments revealed that 3D-mLTS is superior for determining under- or overestimated TSCs while preserving anatomical details. This suggests that the 3D-mLTS method is well suited for the accurate determination of TSC, especially in small focal lesions associated with pathological conditions.

Diffusely appearing white matter in multiple sclerosis: Insights from sodium (23Na) MRI

BACKGROUND

In multiple sclerosis (MS), magnetic resonance imaging (MRI) frequently shows ill-defined areas with intermediate signal intensity between the normal appearing white matter (NAWM) and focal T2-hyperintense lesions, termed "diffusely appearing white matter" (DAWM). Even though several advanced MRI techniques have shown the potential to detect and quantify subtle commonly not visible microscopic tissue changes, to date only a few advanced MRI studies investigated DAWM changes in a quantitative manner. The aim of this study was to detect and quantify tissue abnormalities in the DAWM in comparison to focal lesions and the NAWM in MS patients by sodium (²³Na) MRI.

METHODS

²³Na and conventional MRI were performed in 25 MS patients with DAWM (DAWM⁺) and in 25 sex- and age matched MS patients without DAWM (DAWM^-), as well as in ten healthy controls (HC). Mean total sodium concentrations (TSC) were quantified in the DAWM, NAWM, normal appearing grey matter (NAGM) and in focal MS lesions.

RESULTS

In MS DAWM⁺and DAWM^-, TSC values were increased in the NAGM (DAWM⁺: 44.61 ± 4.09 mM; DAWM^-: 45.37 ± 3.8 mM) and in the NAWM (DAWM⁺: 39.85 ± 3.89 mM; DAWM^-: 39.82 ± 4.25 mM) compared to normal grey and white matter in HC (GM 40.87 ± 3.25 mM, WM 35.9 ± 1.81 mM; p < 0.05 for all comparisons). Interestingly, the DAWM showed similar sodium concentrations (39.32 ± 4.59 mM) to the NAWM (39.85 ± 3.89 mM), whereas TSC values in T1 hypointense (46.53 ± 7.87 mM) and T1 isointense (41.99 ± 6.10 mM) lesions were significantly higher than in the DAWM (p < 0.001 and 0.017 respectively).

CONCLUSION

²³Na MRI is confirmed as a sensitive marker of even subtle tissue abnormalities. DAWM sodium levels are increased and comparable to the abnormalities in NAWM, suggesting pathological changes less severe than in focal lesions comparable to what is expected in the NAWM.

Ultra-high-field 7-T MRI in multiple sclerosis and other demyelinating diseases: from pathology to clinical practice

Magnetic resonance imaging (MRI) is essential for the early diagnosis of multiple sclerosis (MS), for investigating the disease pathophysiology, and for discriminating MS from other neurological diseases. Ultra-high-field strength (7-T) MRI provides a new tool for studying MS and other demyelinating diseases both in research and in clinical settings. We present an overview of 7-T MRI application in MS focusing on increased sensitivity and specificity for lesion detection and characterisation in the brain and spinal cord, central vein sign identification, and leptomeningeal enhancement detection. We also discuss the role of 7-T MRI in improving our understanding of MS pathophysiology with the aid of metabolic imaging. In addition, we present 7-T MRI applications in other demyelinating diseases. 7-T MRI allows better detection of the anatomical, pathological, and functional features of MS, thus improving our understanding of MS pathology in vivo. 7-T MRI also represents a potential tool for earlier and more accurate diagnosis.

Frontiers of Sodium MRI Revisited: From Cartilage to Brain Imaging

Sodium magnetic resonance imaging (²³ Na-MRI) is a highly promising imaging modality that offers the possibility to noninvasively quantify sodium content in the tissue, one of the most relevant parameters for biochemical investigations. Despite its great potential, due to the intrinsically low signal-to-noise ratio (SNR) of sodium imaging generated by low in vivo sodium concentrations, low gyromagnetic ratio, and substantially shorter relaxation times than for proton (¹ H) imaging, ²³ Na-MRI is extremely challenging. In this article, we aim to provide a comprehensive overview of the literature that has been published in the last 10-15 years and which has demonstrated different technical designs for a range of ²³ Na-MRI methods applicable for disease diagnoses and treatment efficacy evaluations. Currently, a wider use of 3.0T and 7.0T systems provide imaging with the expected increase in SNR and, consequently, an increased image resolution and a reduced scanning time. A great interest in translational research has enlarged the field of sodium MRI applications to almost all parts of the body: articular cartilage tendons, spine, heart, breast, muscle, kidney, and brain, etc., and several pathological conditions, such as tumors, neurological and degenerative diseases, and others. The quantitative parameter, tissue sodium concentration, which reflects changes in intracellular sodium concentration, extracellular sodium concentration, and intra-/extracellular volume fractions is becoming acknowledged as a reliable biomarker. Although the great potential of this technique is evident, there must be steady technical development for ²³ Na-MRI to become a standard imaging tool. The future role of sodium imaging is not to be considered as an alternative to ¹ H MRI, but to provide early, diagnostically valuable information about altered metabolism or tissue function associated with disease genesis and progression. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 1.

Sodium in the Relapsing-Remitting Multiple Sclerosis Spinal Cord: Increased Concentrations and Associations With Microstructural Tissue Anisotropy

BACKGROUND

Associations between brain total sodium concentration, disability, and disease progression have recently been reported in multiple sclerosis. However, such measures in spinal cord have not been reported.

PURPOSE

To measure total sodium concentration (TSC) alterations in the cervical spinal cord of people with relapsing-remitting multiple sclerosis (RRMS) and a control cohort using sodium MR spectroscopy (MRS).

STUDY TYPE

Retrospective cohort.

SUBJECTS

Nineteen people with RRMS and 21 healthy controls.

FIELD STRENGTH/SEQUENCE

3 T sodium MRS, diffusion tensor imaging, and 3D gradient echo.

ASSESSMENT

Quantification of total sodium concentration in the cervical cord using a reference phantom. Measures of spinal cord cross-sectional area, fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity from ¹ H MRI. Clinical assessments of 9-Hole Peg Test, 25-Foot Timed walk test, Paced Auditory Serial Addition Test with 3-second intervals, grip strength, vibration sensitivity, and posturography were performed on the RRMS cohort as well as reporting lesions in the C2/3 area.

STATISTICAL TESTS

Multiple linear regression models were run between sodium and clinical scores, cross-sectional area, and diffusion metrics to establish any correlations.

RESULTS

A significant increase in spinal cord total sodium concentration was found in people with RRMS relative to healthy controls (57.6 ± 18 mmol and 38.0 ± 8.6 mmol, respectively, P < 0.001). Increased TSC correlated with reduced fractional anisotropy (P = 0.034) and clinically with decreased mediolateral stability assessed with posturography (P = 0.045).

DATA CONCLUSION

Total sodium concentration in the cervical spinal cord is elevated in RRMS. This alteration is associated with reduced fractional anisotropy, which may be due to changes in tissue microstructure and, hence, in the integrity of spinal cord tissue.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

Sodium and water handling during hemodialysis: new pathophysiologic insights and management approaches for improving outcomes in end-stage kidney disease

Space medicine and new technology such as magnetic resonance imaging of tissue sodium stores (²³NaMRI) have changed our understanding of human sodium homeostasis and pathophysiology. It has become evident that body sodium comprises 3 main components. Two compartments have been traditionally recognized, namely one that is circulating and systemically active via its osmotic action, and one slowly exchangeable pool located in the bones. The third, recently described pool represents sodium stored in skin and muscle interstitium, and it is implicated in cell and biologic activities via local hypertonicity and sodium clearance mechanisms. This in-depth review provides a comprehensive view on the pathophysiology and existing knowledge gaps of systemic hemodynamic and tissue sodium accumulation in dialysis patients. Furthermore, we discuss how the combination of novel technologies to quantitate tissue salt accumulation (e.g., ²³NaMRI) with devices to facilitate the precise attainment of a prescribed hemodialytic sodium mass balance (e.g., sodium and water balancing modules) will improve our therapeutic approach to sodium management in dialysis patients. While prospective studies are required, we think that these new diagnostic and sodium balancing tools will enhance our ability to pursue more personalized therapeutic interventions on sodium and water management, with the eventual goal of improving dialysis patient outcomes.

Comparison of optimized intensity correction methods for 23Na MRI of the human brain using a 32-channel phased array coil at 7 Tesla

PURPOSE

To correct for the non-homogeneous receive profile of a phased array head coil in sodium magnetic resonance imaging (²³Na MRI).

METHODS

²³Na MRI of the human brain (n = 8) was conducted on a 7T MR system using a dual-tuned quadrature ¹H/²³Na transmit/receive birdcage coil, equipped with a 32-channel receive-only array. To correct the inhomogeneous receive profile four different methods were applied: (1) the uncorrected phased array image and an additionally acquired birdcage image as reference image were low-pass filtered and divided by each other. (2) The second method substituted the reference image by a support region. (3) By averaging the individually calculated receive profiles, a universal sensitivity map was obtained and applied. (4) The receive profile was determined by a pre-scanned large uniform phantom. The calculation of the sensitivity maps was optimized in a simulation study using the normalized root-mean-square error (NRMSE). All methods were evaluated in phantom measurements and finally applied to in vivo ²³Na MRI data sets. The in vivo measurements were partial volume corrected and for further evaluation the signal ratio between the outer and inner cerebrospinal fluid compartments (CSF_out:CSF_in) was calculated.

RESULTS

Phantom measurements show the correction of the intensity profile applying the given methods. Compared to the uncorrected phased array image (NRMSE = 0.46, CSF_out:CSF_in = 1.71), the quantitative evaluation of simulated and measured intensity corrected human brain data sets indicates the best performance utilizing the birdcage image (NRMSE = 0.39, CSF_out:CSF_in = 1.00). However, employing a support region (NRMSE = 0.40, CSF_out:CSF_in = 1.17), a universal sensitivity map (NRMSE = 0.41, CSF_out:CSF_in = 1.05) or a pre-scanned sensitivity map (NRMSE = 0.42, CSF_out:CSF_in = 1.07) shows only slightly worse results.

CONCLUSION

Acquiring a birdcage image as reference image to correct for the receive profile demonstrates the best performance. However, when aiming to reduce acquisition time or for measurements without existing birdcage coil, methods that use a support region as reference image, a universal or a pre-scanned sensitivity map provide good alternatives for correction of the receive profile.

Detecting neurodegenerative pathology in multiple sclerosis before irreversible brain tissue loss sets in

Background

Multiple sclerosis (MS) is a complex chronic inflammatory and degenerative disorder of the central nervous system. Accelerated brain volume loss, or also termed atrophy, is currently emerging as a popular imaging marker of neurodegeneration in affected patients, but, unfortunately, can only be reliably interpreted at the time when irreversible tissue damage likely has already occurred. Timing of treatment decisions based on brain atrophy may therefore be viewed as suboptimal.

Main body

This Narrative Review focuses on alternative techniques with the potential of detecting neurodegenerative events in the brain of subjects with MS prior to the atrophic stage. First, metabolic and molecular imaging provide the opportunity to identify early subcellular changes associated with energy dysfunction, which is an assumed core mechanism of axonal degeneration in MS. Second, cerebral hypoperfusion has been observed throughout the entire clinical spectrum of the disorder but it remains an open question whether this serves as an alternative marker of reduced metabolic activity, or exists as an independent contributing process, mediated by endothelin-1 hyperexpression. Third, both metabolic and perfusion alterations may lead to repercussions at the level of network performance and structural connectivity, respectively assessable by functional and diffusion tensor imaging. Fourth and finally, elevated body fluid levels of neurofilaments are gaining interest as a biochemical mirror of axonal damage in a wide range of neurological conditions, with early rises in patients with MS appearing to be predictive of future brain atrophy.

Conclusions

Recent findings from the fields of advanced neuroradiology and neurochemistry provide the promising prospect of demonstrating degenerative brain pathology in patients with MS before atrophy has installed. Although the overall level of evidence on the presented topic is still preliminary, this Review may pave the way for further longitudinal and multimodal studies exploring the relationships between the abovementioned measures, possibly leading to novel insights in early disease mechanisms and therapeutic intervention strategies.

Measuring tissue sodium concentration: Cross-vendor repeatability and reproducibility of 23 Na-MRI across two sites

BACKGROUND

Sodium MRI (23 Na-MRI)-derived biomarkers such as total sodium concentration (TSC) have the potential to provide information on tumor cellularity and the changes in tumor microstructure that occur following therapy.

PURPOSE

To evaluate the repeatability and reproducibility of TSC measurements in the brains of healthy volunteers, providing evidence for the technical validation of 23 Na-MRI-derived biomarkers.

STUDY TYPE

Prospective multicenter study.

SUBJECTS

Eleven volunteers (32 ± 6 years; eight males, three females) were scanned twice at each of two sites.

FIELD STRENGTH/SEQUENCE

Comparable 3D-cones 23 Na-MRI ultrashort echo time acquisitions at 3T.

ASSESSMENT

TSC values, quantified from calibration phantoms placed in the field of view, were obtained from white matter (WM), gray matter (GM), and cerebrospinal fluid (CSF), based on automated segmentation of coregistered 1 H T1 -weighted images and hand-drawn regions of interest by two readers.

STATISTICAL TESTS

Coefficients of variation (CoVs) from mean TSC values were used to assess intrasite repeatability and intersite reproducibility.

RESULTS

Mean GM TSC concentrations (52.1 ± 7.1 mM) were ∼20% higher than for WM (41.8 ± 6.7 mM). Measurements were highly repeatable at both sites with mean scan-rescan CoVs between volunteers and regions of 2% and 4%, respectively. Mean intersite reproducibility CoVs were 3%, 3%, and 6% for WM, GM, and CSF, respectively.

DATA CONCLUSION

These results demonstrate technical validation of sodium MRI-derived biomarkers in healthy volunteers. We also show that comparable 23 Na imaging of the brain can be implemented across different sites and scanners with excellent repeatability and reproducibility.

LEVEL OF EVIDENCE

1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1278-1284.

Venous contribution to sodium MRI in the human brain

PURPOSE

Sodium MRI shows great promise as a marker for cerebral metabolic dysfunction in stroke, brain tumor, and neurodegenerative pathologies. However, cerebral blood vessels, whose volume and function are perturbed in these pathologies, have elevated sodium concentrations relative to surrounding tissue. This study aims to assess whether this fluid compartment could bias measurements of tissue sodium using MRI.

METHODS

Density-weighted and B₁ corrected sodium MRI of the brain was acquired in 9 healthy participants at 4.7T. Veins were identified using co-registered ¹ H T 2 ∗ -weighted images and venous partial volume estimates were calculated by down-sampling the finer spatial resolution venous maps from the T 2 ∗ -weighted images to the coarser spatial resolution of the sodium data. Linear regressions of venous partial volume estimates and sodium signal were performed for regions of interest including just gray matter, just white matter, and all brain tissue.

RESULTS

Linear regression demonstrated a significant venous sodium contribution above the underlying tissue signal. The apparent venous sodium concentrations derived from regression were 65.8 ± 4.5 mM (all brain tissue), 71.0 ± 7.4 mM (gray matter), and 55.0 ± 4.7 mM (white matter).

CONCLUSION

Although the partial vein linear regression did not yield the expected sodium concentration in blood (~87 mM), likely the result of point spread function smearing, this regression highlights that blood compartments may bias brain tissue sodium signals across neurological conditions where blood volumes may differ.

Cortical grey matter sodium accumulation is associated with disability and secondary progressive disease course in relapse-onset multiple sclerosis

OBJECTIVE

Sodium (²³Na)-MRI is an emerging imaging technique to investigate in vivo changes in tissue viability, reflecting neuroaxonal integrity and metabolism. Using an optimised ²³Na-MRI protocol with smaller voxel sizes and improved tissue contrast, we wanted to investigate whether brain total sodium concentration (TSC) is a biomarker for long-term disease outcomes in a cohort of patients with relapse-onset multiple sclerosis (MS), followed from disease onset.

METHODS

We performed a cross-sectional study in 96 patients followed up ~ 15 years after a clinically isolated syndrome (CIS) and 34 healthy controls. Disease course was classified as CIS, relapsing-remitting MS or secondary progressive MS (SPMS). We acquired ¹H-MRI and ²³Na-MRI and calculated the TSC in cortical grey matter (CGM), deep grey matter, normal-appearing white matter (WM) and WM lesions. Multivariable linear regression was used to identify independent associations of tissue-specific TSC with physical disability and cognition, with adjustment for tissue volumes.

RESULTS

TSC in all tissues was higher in patients with MS compared with healthy controls and patients who remained CIS, with differences driven by patients with SPMS. Higher CGM TSC was independently associated with Expanded Disability Status Scale (R²=0.26), timed 25-foot walk test (R²=0.23), 9-hole peg test (R²=0.23), Paced Auditory Serial Addition Test (R²=0.29), Symbol Digit Modalities Test (R²=0.31) and executive function (R²=0.36) test scores, independent of grey matter atrophy.

CONCLUSIONS

Sodium accumulation in CGM reflects underlying neuroaxonal metabolic abnormalities relevant to disease course heterogeneity and disability in relapse-onset MS. TSC and should be considered as an outcome measure in future neuroprotection trials.

Cerebral sodium (23Na) magnetic resonance imaging in patients with migraine - a case-control study

OBJECTIVE

Evaluation of MRI-derived cerebral ²³Na concentrations in patients with migraine in comparison with healthy controls.

MATERIALS AND METHODS

In this case-control study, 24 female migraine patients (mean age, 34 ± 11 years) were enrolled after evaluation of standardized questionnaires. Half (n = 12) of the cohort suffered from migraine, the other half was impaired by both migraine and tension-type headaches (TTH). The combined patient cohort was matched to 12 healthy female controls (mean age, 34 ± 11 years). All participants underwent a cerebral ²³Na-magnetic resonance imaging examination at 3.0 T, which included a T1w MP-RAGE sequence and a 3D density-adapted, radial gradient echo sequence for ²³Na imaging. Circular regions of interests were placed in predetermined anatomic regions: cerebrospinal fluid (CSF), gray and white matter, brain stem, and cerebellum. External ²³Na reference phantoms were used to calculate the total ²³Na tissue concentrations. Pearson's correlation, Kendall Tau, and Wilcoxon rank sum test were used for statistical analysis.

RESULTS

²³Na concentrations of all patients in the CSF were significantly higher than in healthy controls (p < 0.001). The CSF of both the migraine and mixed migraine/TTH group showed significantly increased sodium concentrations compared to the control group (p = 0.007 and p < 0.001). Within the patient cohort, a positive correlation between pain level and TSC in the CSF (r = 0.62) could be observed.

CONCLUSION

MRI-derived cerebral ²³Na concentrations in the CSF of migraine patients were found to be statistically significantly higher than in healthy controls.

KEY POINTS

• Cerebral sodium MRI supports the theory of ionic imbalances and may aid in the challenging pathophysiologic understanding of migraine. • Case-control study shows significantly higher sodium concentrations in cerebrospinal fluid of migraineurs. • Cerebral sodium MRI may become a non-invasive imaging tool for drugs to modulate sodium, and hence migraine, on a molecular level, and influence patient management.

Quantitative Brain Sodium MRI Depicts Corticospinal Impairment in Amyotrophic Lateral Sclerosis

Background Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that mainly affects the upper and lower motor neurons. Recent sodium (²³Na) MRI studies have shown that abnormal sodium concentration is related to neuronal suffering in neurodegenerative conditions. Purpose To use ²³Na MRI to investigate abnormal sodium concentrations and map their distribution in the brains of study participants with ALS as compared with healthy control subjects. Materials and Methods Twenty-seven participants with ALS (mean age, 54 years ± 10 [standard deviation], eight women) and 30 healthy control subjects (mean age, 50 years ± 10; 16 women) were prospectively recruited between September 2015 and October 2017 and were examined by using conventional proton MRI and sodium MRI at 3 T. Voxel-based statistical mapping was used to compare quantitative whole-brain total sodium concentration (TSC) maps in participants with ALS with those in control subjects and to localize regions of abnormal elevated TSC. Potential overlap of abnormal elevated TSC with regions of atrophy as detected with ¹H MRI also was investigated. Results Voxel-based statistical mapping analyses revealed higher sodium concentration in motor regions (bilateral precentral gyri, corticospinal tracts, and the corpus callosum) of participants with ALS (two-sample t test, P < .005; age and sex as covariates). In these regions, mean TSC was higher in participants with ALS (mean, 45.6 mmol/L wet tissue ± 3.2) than in control subjects (mean, 41.8 mmol/L wet tissue ± 2.7; P < .001; Cohen d = 1.28). Brain regions showing higher TSC represented a volume of 15.4 cm³ that did not overlap with gray matter atrophy occupying a volume of 16.9 cm³. Elevated TSC correlated moderately with corticospinal conduction failure assessed with transcranial magnetic stimulation in the right upper limb (Spearman ρ = -0.57; 95% confidence interval: -0.78, -0.16; P = .005; n = 23). Conclusion Quantitative ²³Na MRI is sensitive to alterations of brain sodium homeostasis within disease-relevant regions in patients with amyotrophic lateral sclerosis (ALS). This supports further investigation of abnormal sodium concentration as a potential marker of neurodegenerative processes in patients with ALS that could be used as a secondary endpoint in clinical trials. © RSNA, 2019 Online supplemental material is available for this article.

Multinuclear MRI at Ultrahigh Fields

In this article, an overview of the current developments and research applications for non-proton magnetic resonance imaging (MRI) at ultrahigh magnetic fields (UHFs) is given. Due to technical and methodical advances, efficient MRI of physiologically relevant nuclei, such as Na, Cl, Cl, K, O, or P has become feasible and is of interest to obtain spatially and temporally resolved information that can be used for biomedical and diagnostic applications. Sodium (Na) MRI is the most widespread multinuclear imaging method with applications ranging over all regions of the human body. Na MRI yields the second largest in vivo NMR signal after the clinically used proton signal (H). However, other nuclei such as O and P (energy metabolism) or Cl and K (cell viability) are used in an increasing number of MRI studies at UHF. One major advancement has been the increased availability of whole-body MR scanners with UHFs (B0 ≥7T) expanding the range of detectable nuclei. Nevertheless, efforts in terms of pulse sequence and post-processing developments as well as hardware designs must be made to obtain valuable information in clinically feasible measurement times. This review summarizes the available methods in the field of non-proton UHF MRI, especially for Na MRI, as well as introduces potential applications in clinical research.

Repeatability and reproducibility of cerebral 23Na imaging in healthy subjects

Background

Initial reports of ²³Na magnetic resonance imaging (MRI) date back to the 1970s. However, methodological challenges of the technique hampered its widespread adoption for many years. Recent technical developments have overcome some of these limitations and have led to more optimal conditions for ²³Na-MR imaging. In order to serve as a reliable tool for the assessment of clinical stroke or brain tumor patients, we investigated the repeatability and reproducibility of cerebral sodium (²³Na) imaging in healthy subjects.

Methods

In this prospective, IRB approved study 12 consecutive healthy volunteers (8 female, age 31 ± 8.3) underwent three cerebral ²³Na-MRI examinations at 3.0 T (TimTrio, Siemens Healthineers) distributed between two separate visits with an 8 day interval. For each scan a T1w MP-RAGE sequence for anatomical referencing and a 3D-density-adapted, radial GRE-sequence for ²³Na-imaging were acquired using a dual-tuned (²³Na/¹H) head-coil. On 1 day, these scans were repeated consecutively; on the other day, the scans were performed once. ²³Na-sequences were reconstructed according to the MP-RAGE sequence, allowing direct cross-referencing of ROIs. Circular ROIs were placed in predetermined anatomic regions: gray and white matter (GM, WM), head of the caudate nucleus (HCN), pons, and cerebellum. External ²³Na-reference phantoms were used to calculate the tissue sodium content.

Results

Excellent correlation was found between repeated measurements on the same day (r² = 0.94), as well as on a different day (r² = 0.86). No significant differences were found based on laterality other than in the HCN (63.1 vs. 58.7 mmol/kg WW on the right (p = 0.01)). Pronounced inter-individual differences were identified in all anatomic regions. Moderate to good correlation (0.310 to 0.701) was found between the readers.

Conclusion

Our study has shown that intra-individual ²³Na-concentrations in healthy subjects do not significantly differ after repeated scans on the same day and a pre-set time interval. This confirms the repeatability and reproducibility of cerebral ²³Na-imaging. However, with manual ROI placement in predetermined anatomic landmarks, fluctuations in ²³Na-concentrations can be observed.

Feasibility study of a double resonant 8-channel 1H/ 8-channel 23Na receive-only head coil at 3 Tesla

Sodium (²³Na) magnetic resonance imaging (MRI), especially brain applications are increasingly interesting since sodium MRI can provide additional information about tissue viability and vitality. In order to include sodium MRI in the clinical routine, a single RF setup is preferable which provides high sodium sensitivity and full proton performance in terms of signal-to-noise ratio (SNR) and parallel imaging performance. The aim of this work was to evaluate the feasibility of a double resonant receive (Rx) coil array for proton and sodium head MRI. The coil was designed to provide high sodium SNR and full proton performance comparable to commercial coils which are optimized for sodium MRI or for proton MRI, respectively. A measurement setup was built which comprised an 8-channel Rx degenerate Birdcage for sodium imaging and an 8-channel Rx array for proton imaging. The performance of the coil was evaluated against commercial sodium and proton coils using phantom and in-vivo measurements of two healthy volunteers.