Mitral annular disjunction in out-of-hospital cardiac arrest patients-a retrospective cardiac MRI study

BACKGROUND

Mitral annular disjunction (MAD), defined as defective attachment of the mitral annulus to the ventricular myocardium, has recently been linked to malignant arrhythmias. However, its role and prognostic significance in patients requiring cardiopulmonary resuscitation (CPR) remain unknown. This retrospective analysis aimed to describe the prevalence and significance of MAD by cardiac magnetic resonance (CMR) imaging in out-of-hospital cardiac arrest (OHCA) patients.

METHODS

Eighty-six patients with OHCA and a CMR scan 5 days after CPR (interquartile range (IQR): 49 days before - 9 days after) were included. MAD was defined as disjunction-extent ≥ 1 mm in CMR long-axis cine-images. Medical records were screened for laboratory parameters, comorbidities, and a history of arrhythmia.

RESULTS

In 34 patients (40%), no underlying cause for OHCA was found during hospitalization despite profound diagnostics. Unknown-cause OHCA patients showed a higher prevalence of MAD compared to definite-cause patients (56% vs. 10%, p < 0.001) and had a MAD-extent of 6.3 mm (IQR: 4.4-10.3); moreover, these patients were significantly younger (43 years vs. 61 years, p < 0.001), more often female (74% vs. 21%, p < 0.001) and had fewer comorbidities (hypertension, hypercholesterolemia, coronary artery disease, all p < 0.005). By logistic regression analysis, the presence of MAD remained significantly associated with OHCA of unknown cause (odds ratio: 8.49, 95% confidence interval: 2.37-30.41, p = 0.001) after adjustment for age, presence of hypertension, and hypercholesterolemia.

CONCLUSIONS

MAD is rather common in OHCA patients without definitive aetiology undergoing CMR. The presence of MAD was independently associated to OHCA without an identifiable trigger. Further research is needed to understand the exact role of MAD in OHCA patients.

A Blinded Evaluation of Brain Morphometry for Differential Diagnosis of Atypical Parkinsonism

BACKGROUND

Advanced imaging techniques have been studied for differential diagnosis between PD, MSA, and PSP.

OBJECTIVES

This study aims to validate the utility of individual voxel-based morphometry techniques for atypical parkinsonism in a blinded fashion.

METHODS

Forty-eight healthy controls (HC) T1-WI were used to develop a referential dataset and fit a general linear model after segmentation into gray matter (GM) and white matter (WM) compartments. Segmented GM and WM with PD (n = 96), MSA (n = 18), and PSP (n = 20) were transformed into z-scores using the statistics of referential HC and individual voxel-based z-score maps were generated. An imaging diagnosis was assigned by two independent raters (trained and untrained) blinded to clinical information and final diagnosis. Furthermore, we developed an observer-independent index for ROI-based automated differentiation.

RESULTS

The diagnostic performance using voxel-based z-score maps by rater 1 and rater 2 for MSA yielded sensitivities: 0.89, 0.94 (95% CI: 0.74-1.00, 0.84-1.00), specificities: 0.94, 0.80 (0.90-0.98, 0.73-0.87); for PSP, sensitivities: 0.85, 0.90 (0.69-1.00, 0.77-1.00), specificities: 0.98, 0.94 (0.96-1.00, 0.90-0.98). Interrater agreement was good for MSA (Cohen's kappa: 0.61), and excellent for PSP (0.84). Receiver operating characteristic analysis using the ROI-based new index showed an area under the curve (AUC): 0.89 (0.77-1.00) for MSA, and 0.99 (0.98-1.00) for PSP.

CONCLUSIONS

These evaluations provide support for the utility of this imaging technique in the differential diagnosis of atypical parkinsonism demonstrating a remarkably high differentiation accuracy for PSP, suggesting potential use in clinical settings in the future.

Cervical artery tortuosity-a reliable semi-automated magnetic resonance-based method

Background

Assessments of subclinical connective tissue disorders depend on complex approaches, emphasizing the need for more accessible methods applicable to clinical routine. Therefore, we aimed to establish a reliable approach assessing cervical vessel tortuosity, which is known to be associated with such disorders.

Methods

Magnetic resonance angiography (MRA) images of ReSect study participants [single-center prospective cohort of spontaneous cervical artery dissection (sCeAD) patients] were used. Each patient underwent the same magnetic resonance imaging (MRI) protocol. The segmentation procedure was done using MATrix LABoratory 9.4 [up-sampling of raw MRA images, distance metric (DM) calculation], ITK-SNAP [region of interest (ROI) determination, vessel segmentation] and Vascular Modelling ToolKit (centerline determination). To assess inter-user variability and validity, we (I) had two blinded independent users segment all arteries and we (II) compared the results of our method to visual appraisal of vessel tortuosity done by two blinded expert neuro-radiologists.

Results

A total of 526 extracranial cervical arteries were available for analysis. The inter-user variability of our method users was below 0.5% throughout. Overall, our method outperformed the visual tortuosity appraisal, as the visual grading underestimated the DM in 38.8% subjects when tasked to assess overall cervical artery tortuosity (both vertebral and internal carotid arteries) and in 16.6% and 33.3% respectively if tasked to grade anterior or posterior circulation separately.

Conclusions

We present a reliable method to assess cervical artery tortuosity derived from MRA images applicable in clinical routine and future research investigating the potential correlation of sCeAD and connective tissue disorder.

Cumulative Effective Dose During Fluoroscopically Guided Interventions (FGI): Analysis of More Than 5000 FGIs in a Single European Center

BACKGROUND

The number of fluoroscopically guided interventions (FGI) has increased significantly over time. However, little attention has been paid to possible stochastic radiation effects. The aim of this retrospective study was to investigate the number of patients who received cumulative effective doses over 100 mSv during FGI procedures.

MATERIAL AND METHODS

Five thousand five hundred and fifty four classified FGI procedures were included. Radiation dose data, retrieved from an in-house-dose-management system, was analysed. Effective doses and cumulative effective doses (CED) were calculated. Patients who received a CED > 100 mSv were identified. Radiology reports, patient age, imaging and clinical data of these patients were used to identify reasons for CED ≥ 100 mSv.

RESULTS

One Hundred and thirty two (41.1% female) of 3981 patients received a CED > 100 mSy, with a mean CED of 173.5 ± 84.5 mSv. Mean age at first intervention was 66.1 ± 11.7 years. 81 (61.4%) of 132 were older than 64 years, one patient was < 30 years. 110 patients received ≥ 100 mSv within one year (83.4%), through FGIs: EVAR, pelvic/mesenteric interventions (stent or embolization), hepatic interventions (chemoembolization, TIPSS), embolization of cerebral aneurysms or arterio-venous-malformations.

CONCLUSIONS

Substantial CED may occur in a small but not ignorable fraction of patients (~ 3%) undergoing FGIs. Approximately 2/3rd of patients may most likely not encounter radiation-related stochastic effects due to life-threatening diseases and age at first treatment > 65 years but 1/3rd may. Patients undergoing more than one FGI (77%) carry a higher risk of accumulating effective doses > 100 mSv. Remarkably, 23% received a mean CED 162.2 ± 72.3 mSv in a single procedure.

Endovascular stroke therapy outside core working hours in a nationwide stroke system

BACKGROUND

Endovascular therapy (EVT) has been established as a major component in the acute treatment of large vessel occlusion stroke. However, it is unclear whether outcome and other treatment-related factors differ if patients are treated within or outside core working hours.

METHODS

We analyzed data from the prospective nationwide Austrian Stroke Unit Registry capturing all consecutive stroke patients treated with EVT between 2016 and 2020. Patients were trichotomized according to the time of groin puncture into treatment within regular working hours (08:00-13:59), afternoon/evening (14:00-21:59) and night-time (22:00-07:59). Additionally, we analyzed 12 EVT treatment windows with equal patient numbers. Main outcome variables included favorable outcome (modified Rankin Scale scores of 0-2) 3 months post-stroke as well as procedural time metrics, recanalization status and complications.

RESULTS

We analyzed 2916 patients (median age 74 years, 50.7% female) who underwent EVT. Patients treated within core working hours more frequently had a favorable outcome (42.6% vs 36.1% treated in the afternoon/evening vs 35.8% treated at night-time; p=0.007). Similar results were found when analyzing 12 treatment windows. All these differences remained significant in multivariable analysis adjusting for outcome-relevant co-factors. Onset-to-recanalization time was considerably longer outside core working hours, which was mainly explained by longer door-to-groin time (p<0.001). There was no difference in the number of passes, recanalization status, groin-to-recanalization time and EVT-related complications.

CONCLUSIONS

The findings of delayed intrahospital EVT workflows and worse functional outcomes outside core working hours in this nationwide registry are relevant for optimization of stroke care, and might be applicable to other countries with similar settings.

Clinical characteristics and outcome in expansive compared with steno-occlusive mural hematoma in spontaneous cervical artery dissection

BACKGROUND

Spontaneous cervical artery dissection (sCeAD) is one of the prime causes of ischemic stroke in young adults. Based on vessel wall imaging, steno-occlusive or expansive wall hematomas can be distinguished. It is unclear whether these two distinct morphological phenotypes reflect different pathophysiological processes.

AIM

We aim to evaluate differences in clinical characteristics and long-term recurrence between patients with expansive and steno-occlusive mural wall hematoma in the acute phase.

METHODS

Participants of the ReSect-study, one of the largest single-center cohort studies with long-term follow-up of sCeAD patients, with sufficient magnetic resonance imaging (MRI) were included. All available MRI scans were retrospectively evaluated for patients dichotomized to two groups: (1) mural hematoma causing steno-occlusive pathologies without expansion of total vessel diameter (steno-occlusive hematoma), and (2) mural hematoma causing vessel diameter expansion without lumen stenosis (expansive hematoma). Patients with mixed steno-occlusive and expansive vessel pathologies were excluded from the analysis.

RESULTS

In total, 221 individuals were available for analysis. The pathognomonic vessel wall hematoma was steno-occlusive in 187 (84.6%) and expansive in 34 (15.4%). No difference was seen in patient demographics, clinical status at admission, laboratory parameters, family history, or the frequency of clinical stigmata for connective tissue disorders. Both patients with expansive and steno-occlusive mural hematoma had a high likelihood of suffering cerebral ischemia (64.7 vs 79.7). Still, time from symptom onset to diagnosis was significantly longer in those with expansive dissection (17.8 vs 7.8 days, p = 0.02). Those with expansive dissections were more likely to have upper respiratory infection within 4 weeks prior to dissection (26.5% vs 12.3%, p = 0.03). Upon follow-up, functional outcome was identical and groups did not differ in rate of sCeAD recurrence, but those with expansive mural hematoma at baseline more frequently had residual aneurysmal formation (41.2% vs 11.5%, p < 0.01).

CONCLUSIONS

As cerebral ischemia was frequent in both, our clinical results do not advise for differential treatment or follow-up based on the acute morphological phenotype. There was no clear evidence of a different aetiopathogenesis between patients with steno-occlusive or expansive mural hematoma in the acute phase. More mechanistic approaches are needed to elucidate potential differences in pathomechanism between both entities.

DATA ACCESS

Anonymized data not published within this article will be made available by request from any qualified investigator.

Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial

BACKGROUND

Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice.

METHODS

In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715.

FINDINGS

From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone.

INTERPRETATION

Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection.

FUNDING

EU Horizon 2020.

Somatostatin receptor subtype expression and radiomics from DWI-MRI represent SUV of [68Ga]Ga-DOTATOC PET in patients with meningioma

OBJECTIVE

This retrospective study aimed to analyse the correlation between somatostatin receptor subtypes (SSTR 1-5) and maximum standardized uptake value (SUVmax) in meningioma patients using Gallium-68 DOTA-D-Phe1-Tyr3-octreotide Positron Emission Tomography ([68Ga]Ga-DOTATOC PET). Secondly, we developed a radiomic model based on apparent diffusion coefficient (ADC) maps derived from diffusion weighted magnetic resonance images (DWI MRI) to reproduce SUVmax.

METHOD

The study included 51 patients who underwent MRI and [68Ga]Ga-DOTATOC PET before meningioma surgery. SUVmax values were quantified from PET images and tumour areas were segmented on post-contrast T1-weighted MRI and mapped to ADC maps. A total of 1940 radiomic features were extracted from the tumour area on each ADC map. A random forest regression model was trained to predict SUVmax and the model's performance was evaluated using repeated nested cross-validation. The expression of SSTR subtypes was quantified in 18 surgical specimens and compared to SUVmax values.

RESULTS

The random forest regression model successfully predicted SUVmax values with a significant correlation observed in all 100 repeats (p < 0.05). The mean Pearson's r was 0.42 ± 0.07 SD, and the root mean square error (RMSE) was 28.46 ± 0.16. SSTR subtypes 2A, 2B, and 5 showed significant correlations with SUVmax values (p < 0.001, R2 = 0.669; p = 0.001, R2 = 0.393; and p = 0.012, R2 = 0.235, respectively).

CONCLUSION

SSTR subtypes 2A, 2B, and 5 correlated significantly with SUVmax in meningioma patients. The developed radiomic model based on ADC maps effectively reproduces SUVmax using [68Ga]Ga-DOTATOC PET.

Noninvasive CSF shunt patency evaluation by superb microvascular imaging

Occlusion of a ventriculoperitoneal shunt system is a potentially life-threatening complication in patients suffering from hydrocephalus. However, there is no imaging established as standard approach in this acute setting. In the present study, we evaluate the use of superb microvascular imaging for investigation of the patency of ventriculoperitoneal shunt systems. Simulation of low flow rates of cerebrospinal fluid through a small diameter CSF shunt system was performed in a dedicated phantom in order to proof the principle of superb microvascular imaging (SMI) being feasible for the measurement of slow CSF flow through the dedicated CSF shunt system. SMI is able to detect low flow rates in CSF shunt systems effectively and fast. Visualization of a Duplex ultrasound flow and Doppler wave pattern in the VP shunt system after the reservoir has been pressed confirms patency. SMI is an effective method for evaluating CSF shunt patency and diagnosing shunt obstruction. This bears the potential to facilitate evaluation of clinically symptomatic VP shunt patients in an acute setting. Further evaluation of ultrasound flow patterns is granted.

Patterns of acute ischemic stroke and intracranial hemorrhage in patients with COVID-19 : Results of a retrospective multicenter neuroimaging-based study from three central European countries

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an infection which can affect the central nervous system. In this study, we sought to investigate associations between neuroimaging findings with clinical, demographic, blood and cerebrospinal fluid (CSF) parameters, pre-existing conditions and the severity of acute COVID-19.

MATERIALS AND METHODS

Retrospective multicenter data retrieval from 10 university medical centers in Germany, Switzerland and Austria between February 2020 and September 2021. We included patients with COVID-19, acute neurological symptoms and cranial imaging. We collected demographics, neurological symptoms, COVID-19 severity, results of cranial imaging, blood and CSF parameters during the hospital stay.

RESULTS

442 patients could be included. COVID-19 severity was mild in 124 (28.1%) patients (moderate n = 134/30.3%, severe n = 43/9.7%, critical n = 141/31.9%). 220 patients (49.8%) presented with respiratory symptoms, 167 (37.8%) presented with neurological symptoms first. Acute ischemic stroke (AIS) was detected in 70 (15.8%), intracranial hemorrhage (IH) in 48 (10.9%) patients. Typical risk factors were associated with AIS; extracorporeal membrane oxygenation therapy and invasive ventilation with IH. No association was found between the severity of COVID-19 or blood/CSF parameters and the occurrence of AIS or IH.

DISCUSSION

AIS was the most common finding on cranial imaging. IH was more prevalent than expected but a less common finding than AIS. Patients with IH had a distinct clinical profile compared to patients with AIS. There was no association between AIS or IH and the severity of COVID-19. A considerable proportion of patients presented with neurological symptoms first. Laboratory parameters have limited value as a screening tool.

Mechanical thrombectomy for acute ischemic stroke in COVID-19 patients: multicenter experience in 111 cases

BACKGROUND

Data on the frequency and outcome of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in patients with COVID-19 is limited. Addressing this subject, we report our multicenter experience.

METHODS

A retrospective cohort study was performed of consecutive acute stroke patients with COVID-19 infection treated with MT at 26 tertiary care centers between January 2020 and November 2021. Baseline demographics, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at discharge and 90 days were noted.

RESULTS

We identified 111 out of 11 365 (1%) patients with acute or subsided COVID-19 infection who underwent MT due to LVO. Cardioembolic events were the most common etiology for LVO (38.7%). Median baseline National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score were 16 (IQR 11.5-20) and 9 (IQR 7-10), respectively. Successful reperfusion (mTICI ≥2b) was achieved in 97/111 (87.4%) patients and 46/111 (41.4%) patients were reperfused completely. The procedure-related complication rate was 12.6% (14/111). Functional independence was achieved in 20/108 (18.5%) patients at discharge and 14/66 (21.2%) at 90 days follow-up. The in-hospital mortality rate was 30.6% (33/108). In the subgroup analysis, patients with severe acute COVID-19 infection requiring intubation had a mortality rate twice as high as patients with mild or moderate acute COVID-19 infection. Acute respiratory failure requiring ventilation and time interval from symptom onset to groin puncture were independent predictors for an unfavorable outcome in a logistic regression analysis.

CONCLUSION

Our study showed a poor clinical outcome and high mortality, especially in patients with severe acute COVID-19 infection undergoing MT due to LVO.

Revisiting brain iron deficiency in restless legs syndrome using magnetic resonance imaging

•

Increased iron in RLS was found in the caudate, putamen and red nucleus.

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A meta-analysis revealed no significant evidence of reduced iron in RLS as assessed by MRI.

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Evidence suggestive of publication bias for results on the substantia nigra was found.

•

Our results support the view that brain iron mobilization or homeostasis is impaired in RLS.

Study objectives

Studies on brain iron content in restless legs syndrome (RLS) using magnetic resonance imaging (MRI) are heterogeneous. In this study, we sought to leverage the availability of a large dataset including a range of iron-sensitive MRI techniques to reassess the association between brain iron content and RLS with added statistical power and to compare these results to previous studies.

Methods

The relaxation rates R₂, R₂′, and R₂* and quantitative susceptibility are MRI parameters strongly correlated to iron content. In general, these parameters are sensitive to magnetic field variations caused by iron particles. These parameters were quantified within iron-rich brain regions using a fully automatized approach in a cohort of 72 RLS patients and individually age and gender-matched healthy controls identified from an existing dataset acquired at the Sleep Laboratory of the Department of Neurology, Medical University of Innsbruck. 3 T-MRI measures were corrected for age and volume of the segmented brain nuclei and results were compared with previous findings in a meta-analysis.

Results

In our cohort, RLS patients had increased R₂* signal in the caudate and increased quantitative susceptibility signal in the putamen and the red nucleus compared to controls, suggesting increased iron content in these areas. The meta-analysis revealed no significant pooled effect across all brain regions. Furthermore, potential publication bias was identified for the substantia nigra.

Conclusions

Normal and increased iron content of subcortical brain areas detected in this study is not in line with the hypothesis of reduced brain iron storage, but favors CSF investigations and post mortem studies indicating alteration of brain iron mobilization and homeostasis in RLS.

Prevalence of Monosodium Urate (MSU) Deposits in Cadavers Detected by Dual-Energy Computed Tomography (DECT)

Background: Dual-energy computed tomography (DECT) allows direct visualization of monosodium urate (MSU) deposits in joints and soft tissues. Purpose: To describe the distribution of MSU deposits in cadavers using DECT in the head, body trunk, and feet. Materials and Methods: A total of 49 cadavers (41 embalmed and 8 fresh cadavers; 20 male, 29 female; mean age, 79.5 years; SD ± 11.3; range 52–95) of unknown clinical history underwent DECT to assess MSU deposits in the head, body trunk, and feet. Lens, thoracic aorta, and foot tendon dissections of fresh cadavers were used to verify MSU deposits by polarizing light microscopy. Results: 33/41 embalmed cadavers (80.5%) showed MSU deposits within the thoracic aorta. 11/41 cadavers (26.8%) showed MSU deposits within the metatarsophalangeal (MTP) joints and 46.3% of cadavers demonstrated MSU deposits within foot tendons, larger than and equal to 5 mm. No MSU deposits were detected in the cranium/intracerebral vessels, or the coronary arteries. Microscopy used as a gold standard could verify the presence of MSU deposits within the lens, thoracic aorta, or foot tendons in eight fresh cadavers. Conclusions: Microscopy confirmed the presence of MSU deposits in fresh cadavers within the lens, thoracic aorta, and foot tendons, whereas no MSU deposits could be detected in cranium/intracerebral vessels or coronary arteries. DECT may offer great potential as a screening tool to detect MSU deposits and measure the total uric acid burden in the body. The clinical impact of this cadaver study in terms of assessment of MSU burden should be further proven.

Investigating the Migraine Cycle over 21 Consecutive Days Using Proton Magnetic Resonance Spectroscopy and Resting-State fMRI: A Pilot Study

Recent neuroimaging studies have revealed important aspects of the underlying pathophysiological mechanisms of migraine suggesting abnormal brain energy metabolism and altered functional connectivity. Proton magnetic resonance spectroscopy (1H-MRS) studies investigated migraine patients in the interictal or ictal state. This first-of-its-kind study aimed to investigate the whole migraine cycle using 1H-MRS and resting-state functional magnetic resonance imaging (fMRI). A migraine patient underwent 1H-MRS and resting-state fMRI for 21 consecutive days, regardless of whether he was in an interictal or ictal state. Metabolite ratios were assessed and compared to the intrinsic connectivity of subcortical brain areas. Probable migraine phase-dependent changes in N-acetyl aspartate (NAA)/total creatine (tCr) and choline (Cho)/tCr levels are found in the left occipital lobe and left basal ganglia. NAA reflects neuronal integrity and Cho cellular membrane turnover. Such abnormalities may increase the susceptibility to excitatory migraine triggers. Functional connectivity between the right hippocampus and right or left pallidum was strongly correlated to the NAA/Cho ratio in the right thalamus, suggesting neurochemical modulation of these brain areas through thalamic connections. To draw statistically significant conclusions a larger cohort is needed.

Development and Validation of Automated Magnetic Resonance Parkinsonism Index 2.0 to Distinguish Progressive Supranuclear Palsy‐Parkinsonism From Parkinson's Disease

Background

Differentiating progressive supranuclear palsy‐parkinsonism (PSP‐P) from Parkinson's disease (PD) is clinically challenging.

Objective

This study aimed to develop an automated Magnetic Resonance Parkinsonism Index 2.0 (MRPI 2.0) algorithm to distinguish PSP‐P from PD and to validate its diagnostic performance in two large independent cohorts.

Methods

We enrolled 676 participants: a training cohort (n = 346; 43 PSP‐P, 194 PD, and 109 control subjects) from our center and an independent testing cohort (n = 330; 62 PSP‐P, 171 PD, and 97 control subjects) from an international research group. We developed a new in‐house algorithm for MRPI 2.0 calculation and assessed its performance in distinguishing PSP‐P from PD and control subjects in both cohorts using receiver operating characteristic curves.

Results

The automated MRPI 2.0 showed excellent performance in differentiating patients with PSP‐P from patients with PD and control subjects both in the training cohort (area under the receiver operating characteristic curve [AUC] = 0.93 [95% confidence interval, 0.89–0.98] and AUC = 0.97 [0.93–1.00], respectively) and in the international testing cohort (PSP‐P versus PD, AUC = 0.92 [0.87–0.97]; PSP‐P versus controls, AUC = 0.94 [0.90–0.98]), suggesting the generalizability of the results. The automated MRPI 2.0 also accurately distinguished between PSP‐P and PD in the early stage of the diseases (AUC = 0.91 [0.84–0.97]). A strong correlation (r = 0.91, P < 0.001) was found between automated and manual MRPI 2.0 values.

Conclusions

Our study provides an automated, validated, and generalizable magnetic resonance biomarker to distinguish PSP‐P from PD. The use of the automated MRPI 2.0 algorithm rather than manual measurements could be important to standardize measures in patients with PSP‐P across centers, with a positive impact on multicenter studies and clinical trials involving patients from different geographic regions. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

HFP-QSMGAN: QSM from homodyne-filtered phase images

PURPOSE

Homodyne filtering is a standard preprocessing step in the estimation of SWI. Unfortunately, SWI is not quantitative, and QSM cannot be accurately estimated from filtered phase images. Compared with gradient-echo sequences suitable for computing QSM, SWI is more readily available and is often the only susceptibility-sensitive sequence acquired in the clinical setting. In this project, we aimed to quantify susceptibility from the homodyne-filtered phase (HFP), acquired for computing susceptibility-weighted images, using convolutional neural networks to solve the compounded problem of (1) computing the solution to the inverse dipole problem, and (2) compensating for the effects of the homodyne filtering.

METHODS

Two convolutional neural networks, the U-Net and a modified QSMGAN architecture (HFP-QSMGAN), were trained to predict QSM maps at different TEs from HFP images. The QSM maps were quantified from a gradient-echo sequence acquired in the same individuals using total generalized variation (TGV)-QSM. The QSM maps estimated directly from the HFP were also included for comparison. Voxel-wise predictions and, importantly, regional predictions of susceptibility with adjustment to a reference region, were compared.

RESULTS

Our results indicate that the U-Net model provides more accurate voxel-wise predictions of susceptibility compared with HFP-QSMGAN and HFP-QSM. However, regional estimates of susceptibility predicted by HFP-QSMGAN are more strongly correlated with the values from TGV-QSM compared with those of U-Net and HFP-QSM.

CONCLUSION

Accurate prediction of susceptibility can be achieved from filtered SWI phase using convolutional neural networks.

Head/neck pain characteristics after spontaneous cervical artery dissection in the acute phase and on a long-run

Objective

Head/neck pain is one of the primary symptoms associated with spontaneous cervical artery dissection. Still, data on pain quality, intensity, and long-term dynamics are scarce.

Methods

Spontaneous cervical artery dissection subjects were included if mural hematoma was visualised through T1 fat-saturated MRI at baseline. All available medical records were evaluated and patients were invited to standardised clinical follow-up visits at least 1 year after the index event.

Results

In total, 279 subjects were included in the ReSect-study with head/neck pain being the most frequent symptom of spontaneous cervical artery dissection (220 of 273, 80.6%). Pain was of pulling nature in 107 of 218 (49.1%), and extended to the neck area in 145 of 218 (66.5%). In those with prior headache history, pain was novel in quality in 75.4% (42 of 55). Median patient-reported pain intensity was 5 out of 10 with thunderclap-type headache being uncommon (12 of 218, 5.5%). Prior to hospital admission, head/neck pain rarely responded to self-medication (32 of 218, 14.7%). Characteristics did not differ between subjects with and without cerebral ischemia. Pain resolved completely in all subjects within a median of 13.5 days (IQR 12). Upon follow-up in 42 of 164 (25.6%) novel recurring headache occurred, heterogeneous in quality, localisation and intensity.

Conclusion

We present an in-depth analysis of spontaneous cervical artery dissection-related head/neck pain characteristics and its long-term dynamics.

Qualitative and Quantitative Comparison of Hippocampal Volumetric Software Applications: Do All Roads Lead to Rome?

Brain volumetric software is increasingly suggested for clinical routine. The present study quantifies the agreement across different software applications. Ten cases with and ten gender- and age-adjusted healthy controls without hippocampal atrophy (median age: 70; 25–75% range: 64–77 years and 74; 66–78 years) were retrospectively selected from a previously published cohort of Alzheimer’s dementia patients and normal ageing controls. Hippocampal volumes were computed based on 3 Tesla T1-MPRAGE-sequences with FreeSurfer (FS), Statistical-Parametric-Mapping (SPM; Neuromorphometrics and Hammers atlases), Geodesic-Information-Flows (GIF), Similarity-and-Truth-Estimation-for-Propagated-Segmentations (STEPS), and Quantib™. MTA (medial temporal lobe atrophy) scores were manually rated. Volumetric measures of each individual were compared against the mean of all applications with intraclass correlation coefficients (ICC) and Bland–Altman plots. Comparing against the mean of all methods, moderate to low agreement was present considering categorization of hippocampal volumes into quartiles. ICCs ranged noticeably between applications (left hippocampus (LH): from 0.42 (STEPS) to 0.88 (FS); right hippocampus (RH): from 0.36 (Quantib™) to 0.86 (FS). Mean differences between individual methods and the mean of all methods [mm³] were considerable (LH: FS −209, SPM-Neuromorphometrics −820; SPM-Hammers −1474; Quantib™ −680; GIF 891; STEPS 2218; RH: FS −232, SPM-Neuromorphometrics −745; SPM-Hammers −1547; Quantib™ −723; GIF 982; STEPS 2188). In this clinically relevant sample size with large spread in data ranging from normal aging to severe atrophy, hippocampal volumes derived by well-accepted applications were quantitatively different. Thus, interchangeable use is not recommended.

Neurometabolite correlates with personality and stress in healthy emerging adults: A focus on sex differences

Personality traits have been linked with both brain structure and function. However, the exact relationship between personality traits and other behavioural measures with neurometabolites, measured with proton magnetic resonance spectroscopy, is not clear. Here we investigated the association between behavioural measures (i.e., personality traits, resilience, perceived stress, self-esteem, hopelessness, psychological distress) and metabolite ratios (i.e., of choline-containing compounds [Cho], creatine and phosphocreatine [Cr], and N-acetyl-aspartate [NAA]) in the posterior cingulate cortex (pCC) and the dorsal anterior cingulate cortex (dACC) and surrounding white matter (WM) regions in healthy emerging adults (N = 57, 26 women, mean age=23.40 years, SD=2.50). The pCC and the dACC were selected for their known involvement as important brain network hubs and their association to five factor personality dimensions and other psychological measures. Spectral analysis as well as statistics for demographic, clinical, and imaging data were performed. Correlation and multiple regression analyses were used to test the relationship between metabolite ratios and behavioural scores in the entire sample as well as in female and male participants separately. The entire sample showed significant (p<0.05) negative correlates of stress with the NAA/Cr ratio in the pCC, and of extraversion with WM metabolite ratios. In regards of sex differences, a significantly higher NAA/Cho ratio in the pCC (p<0.05), the dACC (p<0.01), and in the left and right posterior WM matter (p<0.05), and a lower Cho/Cr ratio in the dACC (p<0.01) was detected in women. Moreover, the two sexes differed in regards of metabolite correlates of openness, conscientiousness, extraversion, agreeableness, neuroticism, stress, hopelessness, and self-esteem, and in multiple regression model predictions. Our results point to a role of the ACC in conscientiousness through its involvement in higher-order cognitive control as part of the salience network and internally directed thoughts as part of the default mode network (DMN). Furthermore, the two sexes differ in terms of metabolite correlates of openness and conscientiousness in the pCC, suggesting mental process involvement through the DMN, and of agreeableness in the dACC, possibly through involvement in social cognitive processes, particularly in women. Additionally, our results suggest that the ACC is linked to the so-called Alpha-factor of personality. Our findings on stress correlates contribute to the existing literature of the involvement of the ACC as part of the limbic system. In addition, our results suggest a possible role of the pCC in stress-regulatory processes through a possible co-involvement of stress, hopelessness, and self-esteem in the pCC in men, where higher self-esteem may help to cope with stress.

Invasive validation of a novel approach to determine aortic valve area with phase-contrast cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Background. Echocardiography is considered the standard method for screening and diagnosing aortic valve stenosis. However, inaccuracies in the determination of stroke-volumes by the continuity equation might particularly make the evaluation of patients with low-flow states difficult. Phase-contrast cardiac magnetic resonance (PC-CMR) is a promising tool in overcoming these limitations by the simultaneous determination of flow volumes and velocities across the stenotic valve.

Purpose

The aim of this study is to validate a novel approach based on PC-CMR against the invasive determination of the aortic valve area (AVA).

Methods. PC-CMR was performed in 50 patients with moderate or severe AS (n = 52; age 72 years [interquartile range (IQR) 66 - 78], 38% of patients with low-flow states). All of them were referred to invasive evaluation of aortic stenosis by cardiac catheterization. Additionally, transthoracic echocardiography (TTE) was performed. Aortic valve area (AVA) was determined by PC-CMR (AVAPC-CMR) via plotting momentary flow across the valve against momentary flow velocity. AVAPC-CMR at different time points over the entire cardiac cycle was compared to invasively determined AVA, calculated according to the Gorlin-formula. Stroke volumes (SV) were determined by the Fick-principle, pressure gradients according to the modified Bernoulli-equation.

Results. Mean AVA during the whole systolic phase showed a good correlation (r: 0.544, p &lt; 0.001) with invasive AVA with a small bias (AVACMR: 0.78 cm², IQR: [0.60-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87], bias: 0.08 cm², p = 0.017). Intermethodical correlation and bias of AVA as measured by TTE (AVATTE) and AVAINVASIVE were similar to AVAPC-CMR (AVATTE: 0.81 cm²; IQR: [0.64-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87] r: 0.580, p &lt; 0.001, bias 0.11 cm², p &lt; 0.001). SV by PC-CMR showed a good correlation with Cine-CMR with no significant bias (r: 0.730, p &lt; 0.001; SVPC-CMR: 86 ± 31 ml; SVCine: 85 ± 19 ml). Maximum gradients determined by PC‑CMR were 65 ± 2 9mmHg and showed a good inverse correlation with AVAPC-CMR (r: ‑0.371; p = 0.008).

Conclusion. PC-CMR with continuous determination of flow volumes and flow velocities is able to determine AVA in patients with severe aortic stenosis with a tendency to overestimate AVA compared to invasively determined AVA.

Repeated 31P-MRS in severe traumatic brain injury: Insights into cerebral energy status and altered metabolism

Phosphorous magnetic resonance spectroscopy (31P-MRS) is suited to non-invasively investigate energy metabolism and to detect molecules containing phosphorus in the human brain. The aim of this longitudinal study was to perform 31P-MRS at two different time points (within 72 hours and between day 10-14) after severe traumatic brain injury (sTBI) to reveal alterations in cerebral energy metabolism. Twenty-six ventilated sTBI patients, aged between 20 to 75 years, with a median initial GCS of 5 were prospectively analyzed. 31P-MRS data of the structurally more affected side were compared to data from contralateral normal appearing areas and to data of age- and gender-matched healthy controls. There were no significant intraindividual differences between the lesioned and the less affected side at either of time points. In the acute phase, PCr/ATP and PCr/Pi were significantly elevated whereas PME/PDE and Pi/ATP were significantly decreased in contrast to healthy controls. In the subacute phase these differences gradually dissipated, remaining lower Pi/ATP ratio, and only partly altered levels of PCr/Pi and PME/PDE. Our data affirm that cerebral metabolism is globally altered after sTBI, demonstrating the diffuse impairment of brain bioenergetics at multiple levels, with resultant developments in terms of time.

Characterization and diagnostic potential of diffusion tractography in multiple system atrophy

INTRODUCTION

Microstructural integrity of the middle cerebellar peduncle (MCP) and the putamen captured by diffusion-tensor imaging (DTI) is differentially affected in the parkinsonian and cerebellar variants of multiple system atrophy (MSA-P, MSA-C) compared to Parkinson's disease (PD). The current study applied DTI and tractography in order to 1) characterize the distribution of DTI metrics along the tracts of the MCP and from the putamen in MSA variants, and 2) evaluate the usefulness of combining these measures for the differential diagnosis of MSA-P against PD in the clinical setting.

METHODS

Twenty-nine MSA patients (MSA-C, n = 10; MSA-P, n = 19), with a mean disease duration of 2.8 ± 1.7 years, 19 PD patients, and 27 healthy controls (HC) were included in the study. Automatized tractography with a masking procedure was employed to isolate the MCP tracts. DTI measures along the tracts of the MCP and within the putamen were acquired and jointly used to classify MSA vs. PD, and MSA-P vs. PD. Putamen volume was additionally tested as classification feature in post hoc analyses.

RESULTS

DTI measures within the MCP and putamen showed significant alterations in MSA variants compared to HC and PD. Classification accuracy for MSA vs. PD and MSA-P vs PD using diffusion measures was 91.7% and 89.5%, respectively. When replacing the putaminal DTI measure by a normalized measure of putamen volume classification accuracy improved to 95.8% and 94.7%, respectively.

CONCLUSION

Multimodal information from MCP tractography and putamen volume yields excellent diagnostic accuracy to discriminate between early-to-moderately advanced patients with MSA and PD.

Familial writer's cramp: a clinical clue for inherited coenzyme Q10 deficiency

The spectrum of coenzyme Q10 (CoQ10) deficiency syndromes comprises a variety of disorders, including a form of autosomal recessive cerebellar ataxia (ARCA2) caused by mutations in the AarF domain-containing kinase 3 gene (ADCK3). Due to the potential response to CoQ10 supplementation, a timely diagnosis is crucial. Herein, we describe two siblings with a novel homozygous ADCK3 variant and an unusual presentation consisting of isolated writer's cramp with adult-onset. Cerebellar ataxia developed later in the disease course and remained stable during the follow-up. This report highlights that ARCA2 should be considered in the differential diagnosis of familial writer's cramp.

Short-term meditation training influences brain energy metabolism: A pilot study on 31 P MR spectroscopy

BACKGROUND

Meditation is increasingly attracting interest among neuroimaging researchers for its relevance as a cognitive enhancement technique and several cross-sectional studies have indicated cerebral changes. This longitudinal study applied a distinct and standardized meditative technique with a group of volunteers in a short-term training program to analyze brain metabolic changes.

METHODS

The effect of 7 weeks of meditation exercises (focused attention meditation, FAM) was assessed on 27 healthy volunteers. Changes in cerebral energy metabolism were investigated using ³¹ P-MR spectroscopy. Metabolite ratios were compared before (T1) and after training (T2). Additional questionnaire assessments were included.

RESULTS

The participants performed FAM daily. Depression and anxiety scores revealed a lower level of state anxiety at T2 compared to T1. From T1 to T2, energy metabolism ratios showed the following differences: PCr/ATP increased right occipitally; Pi/ATP decreased bilaterally in the basal ganglia and temporal lobe on the right; PCr/Pi increased in occipital lobe bilaterally, in the basal ganglia and in the temporal lobe on the right side. The pH decreased temporal on the left side and frontal in the right side. The observed changes in the temporal areas and basal ganglia may be interpreted as a higher energetic state, whereas the frontal and occipital areas showed changes that may be related to a down-regulation in ATP turnover, energy state, and oxidative capacity.

CONCLUSIONS

The results of the current study indicate for the first time in a longitudinal study that even short-term training in FAM may have considerable effects on brain energy state with different local energy management in specific brain regions. Especially higher energetic state in basal ganglia may represent altered function in their central role in complex cerebral distributed networks including frontal and temporal areas. Further studies including different forms of relaxation techniques should be performed for more specific and reliable insights.

Diagnostic accuracy of MR planimetry in clinically unclassifiable parkinsonism

INTRODUCTION

Quantitative MR planimetric measurements were reported to discriminate between progressive supranuclear palsy (PSP) and non-PSP parkinsonism, yet few data exist on the usefulness of these markers in early disease stages.

METHODS

The pons-to-midbrain area ratio (P/M) and the Magnetic Resonance Parkinsonism Index (MRPI) as well as new indices, termed P/M2.0 and MRPI2.0, multiplying the former by a ratio of the third ventricle (3rdV) width/frontal horns (FH) width, were calculated on T1-weighted images in 84 patients with clinically unclassifiable neurodegenerative parkinsonism (CUP) at the time of imaging. Areas under the curve (AUCs) of these markers for predicting future PSP was determined. The final clinical diagnosis was made after at least 24 months of follow-up.

RESULTS

Final diagnosis was Parkinson's disease in 55 patients, multiple system atrophy in 12 cases, and PSP in 17. At baseline imaging, patients with a final PSP diagnosis had significantly higher MRPI, P/M, MRPI2.0 and P/M2.0 values compared to the other groups. AUCs in discriminating between future PSP and non-PSP parkinsonism were 0.91 for both the P/M and the MRPI and 0.98 for the P/M2.0 and the MRPI2.0.

CONCLUSIONS

Brainstem-derived MR planimetric measures yield high diagnostic accuracy for separating PSP from non-PSP parkinsonism in early disease stages when clinical criteria are not yet fully met. Consistent with the underlying pathology in PSP, our study suggests that inclusion of 3^rdV width makes P/M2.0 and MRPI2.0 more accurate in diagnosing early stage PSP patients than the P/M and MRPI.

Functional connectivity and topology in patients with restless legs syndrome: a case-control resting-state functional magnetic resonance imaging study

Background and purpose

Functional connectivity studies revealed alterations within thalamic, salience, and default mode networks in restless legs syndrome patients.

Methods

Eighty‐two patients with restless legs syndrome (untreated, n = 30; on dopaminergic medication, n = 42; on alpha‐2‐delta ligands as mono‐ or polytherapy combined with dopaminergic medication, n = 10), and 82 individually age‐ and gender‐matched healthy controls were studied with resting‐state functional magnetic resonance imaging. Connectivity of 12 resting‐state networks was investigated with independent component analysis, and network topology was studied with graph methods among 410 brain regions.

Results

Patients with restless legs syndrome showed significantly higher connectivity within salience (p = 0.029), executive (p = 0.001), and cerebellar (p = 0.041) networks, as well as significantly lower (p < 0.05) cerebello‐frontal communication compared to controls. In addition, they had a significantly higher (p < 0.05) clustering coefficient and local efficiency in motor and frontal regions; lower clustering coefficient in the central sulcus; and lower local efficiency in the central opercular cortex, temporal, parieto‐occipital, cuneus, and occipital regions compared to controls. Untreated patients had significantly lower (p < 0.05) cerebello‐parietal communication compared to healthy controls. Connectivity between the thalamus and frontal regions was significantly increased (p < 0.05) in patients on dopaminergic medication compared to untreated patients and controls.

Conclusions

Networks with higher intranetwork connectivity (i.e., salience, executive, cerebellar) and lower cerebello‐frontal connectivity in the restless legs syndrome patients, as well as lower cerebello‐parietal connectivity in untreated patients, correspond to regions associated with attention, response inhibitory control, and processing of sensory information. Intact cerebello‐parietal communication and increased thalamic connectivity to the prefrontal regions in patients on dopaminergic medication suggests a treatment effect on thalamus.

A New MRI Measure to Early Differentiate Progressive Supranuclear Palsy From De Novo Parkinson's Disease in Clinical Practice: An International Study

BACKGROUND

Enlargement of the third ventricle has been reported in atypical parkinsonism. We investigated whether the measurement of third ventricle width could distinguish Parkinson's disease (PD) from progressive supranuclear palsy (PSP).

METHODS

We assessed a new MR T1-weighted measurement (third ventricle width/internal skull diameter) in a training cohort of 268 participants (98 PD, 73 PSP, 98 controls from our center) and in a testing cohort of 291 participants (82 de novo PD patients and 133 controls from the Parkinson's Progression Markers Initiative, 76 early-stage PSP from an international research group). PD diagnosis was confirmed after a 4-year follow-up. Diagnostic performance of the third ventricle/internal skull diameter was assessed using receiver operating characteristic curve with bootstrapping; the area under the curve of the training cohort was compared with the area under the curve of the testing cohort using the De Long test.

RESULTS

In both cohorts, third ventricle/internal skull diameter values did not differ between PD and controls but were significantly lower in PD than in PSP patients (P < 0.0001). In PD, third ventricle/internal skull diameter values did not change significantly between baseline and follow-up evaluation. Receiver operating characteristic analysis accurately differentiated PD from PSP in the training cohort (area under the curve, 0.94; 95% CI, 91.1-97.6; cutoff, 5.72) and in the testing cohort (area under the curve, 0.91; 95% CI, 87.0-97.0; cutoff,: 5.88), validating the generalizability of the results.

CONCLUSION

Our study provides a new reliable and validated MRI measurement for the early differentiation of PD and PSP. The simplicity and generalizability of this biomarker make it suitable for routine clinical practice and for selection of patients in clinical trials worldwide. © 2020 International Parkinson and Movement Disorder Society.

Cortical reorganization processes in meditation naïve participants induced by 7 weeks focused attention meditation training

BACKGROUND

Based on the evidence that meditation is associated with numerous beneficial effects on well-being and reduced stress-related symptoms, mindfulness-based techniques were increasingly implemented into psychotherapeutic programs. However, different meditation styles and the cross-sectional nature of most previous analyses resulted in a great variety of morphometric findings. The present study aims to elucidate cortical reorganization processes and altered axonal integrity caused by short-term meditation training, and benefits from solely using focused attention meditation (FAM).

METHODS

3 T MRI, including T1-MPRAGE and diffusion-weighted sequences, was performed in 27 healthy, meditation naïve participants (age: 43 ± 12.4 years) pre and post FAM meditation training (duration: 7.3 ± 0.4 weeks). Voxel-based morphometry was applied to assess brain changes in gray and white matter. Questionnaires were filled out by the individuals at both time-points to evaluate quality of life and self-awareness deficits.

RESULTS

The major findings comprised (i) gray matter increases in the insula, the caudate nucleus and frontal cortices, (ii) decreases in extended parietotemporal regions, the right medial prefrontal cortex and the parahippocampal gyrus, as well as (iii) fractional anisotropy increases of the right hippocampus, the basal ganglia and adjacent regions. Regression analysis revealed an association of specific alterations with reduced levels of state anxiety.

CONCLUSIONS

FAM training induced a broad range of dynamic brain alterations even within few weeks of training. Interestingly, this cohort revealed more, and partially different patterns of structural gray matter change compared to prior studies. The broad impact on neuronal organization processes may reflect more general outcomes related to health and well-being.

Automated Analysis of Diffusion-Weighted Magnetic Resonance Imaging for the Differential Diagnosis of Multiple System Atrophy from Parkinson's Disease

Background

Manual region‐of‐interest analysis of putaminal and middle cerebellar peduncle diffusivity distinguishes patients with multiple system atrophy (MSA) and Parkinson's disease (PD) with high diagnostic accuracy. However, a recent meta‐analysis found substantial between‐study heterogeneity of diagnostic accuracy due to the lack of harmonized imaging protocols and standardized analyses pipelines.

Objective

Evaluation of diagnostic accuracy of observer‐independent analysis of microstructural integrity as measured by diffusion‐tensor imaging in patients with MSA and PD.

Methods

A total of 29 patients with MSA and 19 patients with PD (matched for age, gender, and disease duration) with 3 years of follow‐up were investigated with diffusion‐tensor imaging and T1‐weighted magnetic resonance imaging. Automated localization of relevant brain regions was obtained, and mean diffusivity and fractional anisotropy values were averaged within the regions of interest. The classification was performed using a C5.0 hierachical decision tree algorithm.

Results

Mean diffusivity of the middle cerebellar peduncle and cerebellar gray and white matter compartment as well as the putamen were significantly increased in patients with MSA and showed superior effect sizes compared to the volumetric analysis of these regions. A classifier model identified mean diffusivity of the middle cerebellar peduncle and putamen as the most predictive parameters. Cross‐validation of the classification model yields a Cohen's κ and overall diagnostic accuracy of 0.823 and 0.914, respectively.

Conclusion

Analysis of microstructural integrity within the middle cerebellar peduncle and putamen yielded a superior effect size compared to the volumetric measures, resulting in excellent diagnostic accuracy to discriminate patients with MSA from PD in the early to moderate disease stages. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

Extracellular matrix protein signature of recurrent spontaneous cervical artery dissection

OBJECTIVE

To assess whether connective tissue disorder is evident in patients with spontaneous cervical artery dissection and therefore identify patients at risk of recurrence using a cutting-edge quantitative proteomics approach.

METHODS

In the ReSect study, all patients with spontaneous cervical artery dissection treated at the Innsbruck University Hospital since 1996 were invited to attend a standardized clinical follow-up examination. Protein abundance in skin punch biopsies (n = 50) was evaluated by a cutting-edge quantitative proteomics approach (liquid chromatography-mass spectrometry) that has hitherto not been applied to such patients.

RESULTS

Patients with 1-time single-vessel (n = 19) or multiple-vessel (n = 13) dissections did not differ between each other or compared to healthy controls (n = 12) in protein composition. Patients with recurrent spontaneous cervical artery dissection (n = 6), however, showed significantly different expression of 25 proteins compared to the other groups combined. Literature review and Gene Ontology term annotation check revealed that 13 of the differently expressed proteins play a major role in the structural integrity of connective tissue or are linked to connective tissue disorders. These proteins showed clustering to a collagen/elastin cluster and one consisting of desmosome related proteins.

CONCLUSION

This study unravels an extracellular matrix protein signature of recurrent spontaneous cervical artery dissection. In the long run and after large-scale validation, our findings may well assist in identifying patients at risk of recurrent spontaneous cervical artery dissection and thus guide therapy.

Transcallosal, transchoroidal clipping of a hypothalamic collateral vessel aneurysm in Moyamoya disease

Peripheral collateral vessel aneurysms in Moyamoya disease (MMD) remain difficult to treat due to their deep location, small size, and vascular fragility. We report the case of an aneurysm localized in the hypothalamus, which was rapidly increasing in size with repeated hemorrhage despite revascularization surgery. Aneurysm clipping was performed to prevent further progress and rerupture with favorable outcome. To our best knowledge, this is the first description of a hypothalamic aneurysm in MMD being clipped via a transcallosal, transchoroidal approach through the third ventricle.

Toward quantitative neuroimaging biomarkers for Friedreich's ataxia at 7 Tesla: Susceptibility mapping, diffusion imaging, R2 and R1 relaxometry

Friedreich's ataxia (FRDA) is a rare genetic disorder leading to degenerative processes. So far, no effective treatment has been found. Therefore, it is important to assist the development of medication with imaging biomarkers reflecting disease status and progress. Ten FRDA patients (mean age 37 ± 14 years; four female) and 10 age- and sex-matched controls were included. Acquisition of magnetic resonance imaging (MRI) data for quantitative susceptibility mapping, R₁ , R₂ relaxometry and diffusion imaging was performed at 7 Tesla. Results of volume of interest (VOI)-based analyses of the quantitative data were compared with a voxel-based morphometry (VBM) evaluation. Differences between patients and controls were assessed using the analysis of covariance (ANCOVA; p < 0.01) with age and sex as covariates, effect size of group differences, and correlations with disease characteristics with Spearman correlation coefficient. For the VBM analysis, a statistical threshold of 0.001 for uncorrected and 0.05 for corrected p-values was used. Statistically significant differences between FRDA patients and controls were found in five out of twelve investigated structures, and statistically significant correlations with disease characteristics were revealed. Moreover, VBM revealed significant white matter atrophy within regions of the brainstem, and the cerebellum. These regions overlapped partially with brain regions for which significant differences between healthy controls and patients were found in the VOI-based quantitative MRI evaluation. It was shown that two independent analyses provided overlapping results. Moreover, positive results on correlations with disease characteristics were found, indicating that these quantitative MRI parameters could provide more detailed information and assist the search for effective treatments.

Feed-forward neural networks using cerebral MR spectroscopy and DTI might predict neurodevelopmental outcome in preterm neonates

Objectives

We aimed to evaluate the ability of feed-forward neural networks (fNNs) to predict the neurodevelopmental outcome (NDO) of very preterm neonates (VPIs) at 12 months corrected age by using biomarkers of cerebral MR proton spectroscopy (¹H-MRS) and diffusion tensor imaging (DTI) at term-equivalent age (TEA).

Methods

In this prospective study, 300 VPIs born before 32 gestational weeks received an MRI scan at TEA between September 2013 and December 2017. Due to missing or poor-quality spectroscopy data and missing neurodevelopmental tests, 173 VPIs were excluded. Data sets consisting of 103 and 115 VPIs were considered for prediction of motor and cognitive developmental delay, respectively. Five metabolite ratios and two DTI characteristics in six different areas of the brain were evaluated. A feature selection algorithm was developed for receiving a subset of characteristics prevalent for the VPIs with a developmental delay. Finally, the predictors were constructed employing multiple fNNs and fourfold cross-validation.

Results

By employing the constructed fNN predictors, we were able to predict cognitive delays of VPIs with 85.7% sensitivity, 100% specificity, 100% positive predictive value (PPV) and 99.1% negative predictive value (NPV). For the prediction of motor delay, we achieved a sensitivity of 76.9%, a specificity of 98.9%, a PPV of 90.9% and an NPV of 96.7%.

Conclusion

FNNs might be able to predict motor and cognitive development of VPIs at 12 months corrected age when employing biomarkers of cerebral ¹H-MRS and DTI quantified at TEA.

Key Points

• A feed-forward neuronal network is a promising tool for outcome prediction in premature infants.

• Cerebral proton magnetic resonance spectroscopy and diffusion tensor imaging can be used for the construction of early prognostic biomarkers.

• Premature infants that would most benefit from early intervention services can be spotted at the time of optimal neuroplasticity.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07053-8) contains supplementary material, which is available to authorized users.

0010 Functional Brain Connectivity Alterations in Restless Legs Syndrome are Modulated by Dopaminergic Medication

Introduction

Functional brain connectivity studies revealed alterations within thalamic, salience, and default mode networks in patients with restless legs syndrome. The objective of this study was to characterize functional connectivity and network topology in a large cohort of patients with restless legs syndrome compared to healthy controls, and to investigate the modulatory effect of dopaminergic treatment upon connectivity.

Methods

82 patients with restless legs syndrome (untreated, n=30; on dopaminergic medication, n=42; on alpha-2-delta ligands as mono- or polytherapy combined with dopaminergic medication, n=10) and 82 individually age and gender matched healthy controls were studied with resting state functional MRI. Connectivity of twelve resting-state networks was compared with independent component analysis, and among 410 brain regions with graph theoretical modeling.

Results

Patients with restless legs syndrome showed significantly higher connectivity within salience (P=0.029), executive (P=0.001), somatomotor (P=0.050), and cerebellar (P=0.041) networks, as well as significantly (P&lt;0.05) lower cerebello-frontal communication compared to healthy controls. Untreated patients had significantly (P&lt;0.05) lower cerebello-parietal communication compared to healthy controls and connectivity between the thalamus and frontal regions were significantly increased in patients on dopaminergic medication compared to untreated patients and healthy controls (P&lt;0.05).

Conclusion

Networks with higher intra-network connectivity (i.e. salience, executive, somatomotor, cerebellar) and lower between regions connectivity (i.e. cerebello-frontal, cerebello-parietal) in restless legs syndrome correspond to regions associated with attention, response inhibitory control, and processing of sensory information. Dopaminergic medication normalizes the altered cerebello-parietal communication and increases thalamic connectivity to the prefrontal cortex suggesting that these regions are associated with the emergence of symptoms in restless legs syndrome.

Support

The study was funded by a Grant from Translational Research

Fund of the government of Tyrol, Austria, and in-kind resources

of the Medical University of Innsbruck.

Cognitive reserve does not support the retrieval of well-known proper names in older people

OBJECTIVE

To assess the role of cognitive reserve, age, gender and brain structure in proper name retrieval in advanced age.

METHOD

Performance in 2 naming tasks (asking for proper names or common names) and 2 memory tasks was assessed. In separate hierarchical regressions, we evaluated whether retrieval was predicted by gray matter thickness or volume in selected structures (Model 1) and whether the addition of age and gender (Model 2) or of education (Model 3) explained significantly more variance. Participants were healthy persons (ages 70-90 years). Out of 91 individuals, 18 were excluded after inspection of magnetic resonance imaging scans showing relevant white matter changes. The remaining 73 individuals (47 women) showed good cognitive abilities.

RESULTS

Age was a significant predictor for the retrieval of well-known proper names, whereas selected gray matter measures and education had no significant effect. In contrast, education was predictive of common names retrieval and performance in the memory tasks. Gray matter measures predicted performance in the 2 memory tasks.

CONCLUSIONS

Cognitive reserve has a differential effect on cognitive abilities in advances age. Education did not support the retrieval of well-known proper names but positively affected the retrieval of common names and performance in memory tasks. Cognitive reserve has to be considered in neuropsychological diagnostic procedures. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Automated MRI Classification in Progressive Supranuclear Palsy: A Large International Cohort Study

BACKGROUND

The Magnetic Resonance Parkinsonism Index is listed as one of the most reliable imaging morphometric markers for diagnosis of progressive supranuclear palsy (PSP). However, the use of this index in diagnostic workup has been limited until now by the low generalizability of published results because of small monocentric patient cohorts, the lack of data validation in independent patient series, and manual measurements used for index calculation. The objectives of this study were to investigate the generalizability of Magnetic Resonance Parkinsonism Index performance validating previously established cutoff values in a large international cohort of PSP patients subclassified into PSP-Richardson's syndrome and PSP-parkinsonism and to standardize the use of the automated Magnetic Resonance Parkinsonism Index by providing a web-based platform to obtain homogenous measures around the world.

METHODS

In a retrospective international multicenter study, a total of 173 PSP patients and 483 non-PSP participants were enrolled. A web-based platform (https://mrpi.unicz.it) was used to calculate automated Magnetic Resonance Parkinsonism Index values.

RESULTS

Magnetic Resonance Parkinsonism Index values showed optimal performance in differentiating PSP-Richardson's syndrome and PSP-parkinsonism patients from non-PSP participants (93.6% and 86.5% of accuracy, respectively). The Magnetic Resonance Parkinsonism Index was also able to differentiate PSP-Richardson's syndrome and PSP-parkinsonism patients in an early stage of the disease from non-PSP participants (90.1% and 85.9%, respectively). The web-based platform provided the automated Magnetic Resonance Parkinsonism Index calculation in 94% of cases.

CONCLUSIONS

Our study provides the first evidence on the generalizability of automated Magnetic Resonance Parkinsonism Index measures in a large international cohort of PSP-Richardson's syndrome and PSP-parkinsonism patients. The web-based platform enables widespread applicability of the automated Magnetic Resonance Parkinsonism Index to different clinical and research settings. © 2020 International Parkinson and Movement Disorder Society.

No effect of age, gender and total intracranial volume on brainstem MR planimetric measurements

Objectives

MR planimetry of brainstem structures can be helpful for the discrimination of Parkinsonian syndromes. It has been suggested that ageing might influence brainstem MR measurements assessed by MR planimetry, while effects of gender and total intracranial volume (TIV) have not been assessed so far. The aim of this study was to evaluate age, gender and TIV effects on brainstem MR planimetric measures.

Methods

Brainstem MR planimetric measures of diameters (midbrain, pons, middle and superior cerebellar peduncle) and areas (pons and midbrain), the derived ratios, and the magnetic resonance Parkinsonism index (MRPI) were assessed on 1.5-T MR images in a large cohort of 97 healthy controls and analysed for the influence of age, gender and TIV with univariate and multivariate linear models.

Results

Neither gender nor age effects on planimetric measurements were observed in the population relevant for the differential diagnosis of neurodegenerative Parkinsonism, aged 50 to 80 years, except for single area-derived measurements, with gender effects on pontine area (p = 0.013) and age effects on midbrain area (p = 0.037). Results were similar upon inclusion of the TIV in the analyses.

Conclusions

There is no need to correct for age, gender or TIV when using brainstem-derived MR planimetric measurements in the differential diagnosis of neurodegenerative Parkinsonism.

Key Points

• There were no gender effects on single or combined imaging measurements of the brainstem in the population aged 50 to 80 years, the age range relevant for the differential diagnosis of neurodegenerative Parkinsonism (except for pontine area).

• There were no age effects on single or combined imaging measurements of the brainstem in the population aged 50 to 80 years, the age range relevant for the differential diagnosis of neurodegenerative Parkinsonism (except for midbrain area).

• There is no need for age- or gender-specific cut-offs for the relevant age group.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06504-1) contains supplementary material, which is available to authorized users.

Delayed Resolution of Cerebral Edema Is Associated With Poor Outcome After Nontraumatic Subarachnoid Hemorrhage

Background and Purpose- Global cerebral edema occurs in up to 57% of patients with subarachnoid hemorrhage (SAH) and is associated with prolonged hospital stay and poor outcome. Recently, admission brain edema was successfully graded using a simplified computed tomography-based semiquantitative score (subarachnoid hemorrhage early brain edema score [SEBES]). Longitudinal evaluation of the SEBES grade may discriminate patients with rapid and delayed edema resolution after SAH. Here, we aimed to describe the resolution of brain edema and to study the relationship between this radiographic biomarker and hospital course and outcome after SAH. Methods- For the current observational cohort study, computed tomography scans of 283 consecutive nontraumatic SAH patients admitted to the neurological intensive care unit of a tertiary hospital were graded based on the absence of visible sulci at 2 predefined brain tissue levels in each hemisphere (SEBES ranging from 0 to 4). A score of ≥3 was defined as high-grade SEBES. Multivariable regression models using generalized linear models were used to identify associated factors with delayed edema resolution based on the median time to resolution (SEBES ≤2) in SAH survivors. Results- Patients were 57 years old (interquartile range, 48-68) and presented with a median admission Hunt and Hess grade of 3 (interquartile range, 1-5). High-grade SEBES was common (106/283, 37%) and resolved within a median of 8 days (interquartile range, 4-15) in survivors (N=80). Factors associated with delayed edema resolution were early (<72 hours) hypernatremia (>150 mmol/L; adjusted odds ratio [adjOR], 4.88; 95% CI, 1.68-14.18), leukocytosis (>15 G/L; adjOR, 3.14; 95% CI, 1.24-8.77), hyperchloremia (>121 mmol/L; adjOR, 5.24; 95% CI, 1.64-16.76), and female sex (adjOR, 3.71; 95% CI, 1.01-13.64) after adjusting for admission Hunt and Hess grade and age. Delayed brain edema resolution was an independent predictor of worse functional 3-month outcome (adjOR, 2.52; 95% CI, 1.07-5.92). Conclusions- Our data suggest that repeated quantification of the SEBES can identify SAH patients with delayed edema resolution. Based on its' prognostic value as radiographic biomarker, the SEBES may be integrated in future trials aiming to improve edema resolution after SAH.

Second language learning induces grey matter volume increase in people with multiple sclerosis

Background

Grey matter volume (GMV) decline is a frequent finding in multiple sclerosis (MS), the most common chronic neurological disease in young adults. Increases of GMV were detected in language related brain regions following second language (L2) learning in healthy adults. Effects of L2 learning in people with MS (pwMS) have not been investigated so far.

Methods

This study prospectively evaluated the potential of an eight-week L2 training on grey matter plasticity measured by 3T-MRI, L2 proficiency and health-related quality of life (HRQoL) in people with relapsing-remitting MS (pwMS, n = 11) and healthy, sex- and age-matched controls (HCs; n = 12).

Results

Categorical voxel-based analysis revealed significantly less GMV bilaterally of the insula extending to the temporal pole in pwMS at baseline. Following L2 training, significant increases of GMV were evident in the right hippocampus, parahippocampus and putamen of pwMS and in the left insula of HCs. L2 training resulted in significant improvements of listening comprehension, speaking fluency and vocabulary knowledge in both pwMS and HCs. GMV increases of right hippocampus and parahippocampus significantly correlated with vocabulary knowledge gain and L2 learning was associated with a significant increase of HRQoL in pwMS.

Conclusion

Our findings demonstrate distinct patterns of GMV increases of language related brain regions in pwMS and HCs and indicate disease-related compensatory cortical and subcortical plasticity to acquire L2 proficiency in pwMS.

Mapping the human brainstem: Brain nuclei and fiber tracts at 3 T and 7 T

Structural high-resolution imaging of the brainstem can be of high importance in clinical practice. However, ultra-high field magnetic resonance imaging (MRI) is still restricted in use due to limited availability. Therefore, quantitative MRI techniques (quantitative susceptibility mapping [QSM], relaxation measurements [ R2* , R₁ ], diffusion tensor imaging [DTI]) and T₂ - and proton density (PD)-weighted imaging in the human brainstem at 3 T and 7 T are compared. Five healthy volunteers (mean age: 21.5 ± 1.9 years) were measured at 3 T and 7 T using multi-echo gradient echo sequences for susceptibility mapping and R2* relaxometry, magnetization-prepared 2 rapid acquisition gradient echo sequences for R₁ relaxometry, turbo-spin echo sequences for PD- and T₂ -weighted imaging and readout-segmented echo planar sequences for DTI. Susceptibility maps were computed using Laplacian-based phase unwrapping, V-SHARP for background field removal and the streaking artifact reduction for QSM algorithm for dipole inversion. Contrast-to-noise ratios (CNRs) were determined at 3 T and 7 T in ten volumes of interest (VOIs). Data acquired at 7 T showed higher CNR. However, in four VOIs, lower CNR was observed for R2* at 7 T. QSM was shown to be the contrast with which the highest number of structures could be identified. The depiction of very fine tracts such as the medial longitudinal fasciculus throughout the brainstem was only possible in susceptibility maps acquired at 7 T. DTI effectively showed the main tracts (crus cerebri, transverse pontine fibers, corticospinal tract, middle and superior cerebellar peduncle, pontocerebellar tract, and pyramid) at both field strengths. Assessing the brainstem with quantitative MRI methods such as QSM, R2* , as well as PD- and T₂ -weighted imaging with great detail, is also possible at 3 T, especially when using susceptibility mapping calculated from a gradient echo sequence with a wide range of echo times from 10.5 to 52.5 ms. However, tracing smallest structures strongly benefits from imaging at ultra-high field.

Multimodal Magnetic Resonance Imaging reveals alterations of sensorimotor circuits in restless legs syndrome

Study Objectives

Integrated information on brain microstructural integrity and iron storage and its impact on the morphometric profile is not available in restless legs syndrome (RLS). We applied multimodal magnetic resonance imaging (MRI) including diffusion tensor imaging, the transverse relaxation rate (R2*), a marker for iron storage, as well as gray and white matter volume measures to characterize RLS-related MRI signal distribution patterns and to analyze their associations with clinical parameters.

Methods

Eighty-seven patients with RLS (mean age 51, range 20–72 years; disease duration, mean 13 years, range 1–46 years, of those untreated n = 30) and 87 healthy control subjects, individually matched for age and gender, were investigated with multimodal 3T MRI.

Results

Volume of the white matter compartment adjacent to the post- and precentral cortex and fractional anisotropy (FA) of the frontopontine tract were both significantly reduced in RLS compared to healthy controls, and these alterations were associated with disease duration (r = 0.25, p = 0.025 and r = 0.23, p = 0.037, respectively). Corresponding gray matter volume increases of the right primary motor cortex in RLS (p &lt; 0.001) were negatively correlated with the right FA signal of the frontopontine tract (r = −0.22; p &lt; 0.05). Iron content evaluated with R2* was reduced in the putamen as well as in temporal and occipital compartments of the RLS cohort compared to the control group (p &lt; 0.01).

Conclusions

Multimodal MRI identified progressing white matter decline of key somatosensory circuits that may underlie the perception of sensory leg discomfort. Increases of gray matter volume of the premotor cortex are likely to be a consequence of functional neuronal reorganization.

Fluid Intake But Not Fluid Balance Is Associated With Poor Outcome in Nontraumatic Subarachnoid Hemorrhage Patients

OBJECTIVES

Optimal fluid management is important in patients with acute brain injury, including subarachnoid hemorrhage. We aimed to examine the relationship between daily fluid intake and fluid balance with hospital complications and functional outcome.

DESIGN

Retrospective observational cohort study.

SETTING

Neurocritical care unit at a tertiary academic medical center.

PATIENTS

Two-hundred thirty-seven consecutive nontraumatic subarachnoid hemorrhage patients admitted to the neurologic ICU between 2010 and 2016.

INTERVENTIONS

Total daily amount of fluids and fluid balance were calculated over 15 days. Using multivariate generalized estimating equation models the association of daily fluid intake and fluid balance with disease severity, hospital complications and poor functional outcome (3-mo modified Rankin Score ≥ 3) was investigated. Additionally, we described the composition of fluids given.

MEASUREMENTS AND MAIN RESULTS

Patients presented with a median admission Hunt and Hess grade of 3 (interquartile range, 1-5) and were 57 years old (interquartile range, 47-67 yr old). A higher daily fluid intake was associated with higher admission Hunt and Hess grade (odds ratio, 1.61; 95% CI, 1.47-1.76; p < 0.001), increased pulmonary fluid accumulation (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21; p = 0.033), prolonged mechanical ventilation (Wald statistic = 20.08; degrees of freedom = 1; p < 0.001), higher daily Subarachnoid hemorrhage Early Brain Edema Score (adjusted odds ratio, 1.11; 95% CI, 1.01-1.22; p = 0.034), occurrence of anemia (adjusted odds ratio, 1.36; 95% CI, 1.20-1.54; p < 0.001), delayed cerebral ischemia (adjusted odds ratio, 1.31; 95% CI, 1.14-1.51; p < 0.001), and poor functional outcome (adjusted odds ratio, 1.25; 95% CI, 1.10-1.41; p < 0.001). Daily fluid balance was associated with higher admission Hunt and Hess grade (odds ratio, 1.09; 95% CI, 1.05-1.13; p < 0.001) and anemia (adjusted odds ratio, 1.17; 95% CI, 1.03-1.33; p = 0.019). The main contributors to fluids were nutritional compounds (31%), IV drugs (30%), and volume substitution (17%).

CONCLUSIONS

Our study demonstrates a significant association of fluid intake but not fluid balance with hospital complications and poor functional outcome in subarachnoid hemorrhage patients. A larger prospective study is needed to confirm our results.

Is an intact hippocampus necessary for answering 3 × 3? - Evidence from Alzheimer's disease

Recent evidence has suggested that the hippocampus supports learning and retrieval of arithmetic facts during childhood and adolescence. Whether the hippocampus is also involved in retrieving overlearned arithmetic facts (such as 3 × 5 = 15) during adult age is open for investigation. In this study, we assessed whether patients with hippocampal atrophy due to Alzheimer's disease (AD) are still able to retrieve overlearned arithmetic facts from memory. Sixteen patients (n = 13 with AD, n = 3 with Mild Cognitive Impairment - MCI) were evaluated using standard radiological, neurological, and neuropsychological test procedures. We adopted a multiple single-case analysis in order to acknowledge possible dissociations between hippocampal degeneration and intact arithmetic fact retrieval. All patients performed a neuropsychological screening battery assessing episodic memory as well as arithmetic processing, and underwent a 3-Tesla MRI procedure. A morphometric analysis comprising estimation of both cortical thickness and hippocampal volume, which also included a subfield analysis, was conducted. All patients had marked hippocampal atrophy (bilateral n = 15, unilateral n = 1) in comparison to healthy matched controls and showed deficits in episodic memory (delayed recall). However, 13 out of 16 patients performed in the average range of standardised norms during retrieval of overlearned arithmetic facts (i.e. multiplication tables). Our results suggest that intact retrieval of consolidated arithmetic facts from memory does not depend on the integrity of the hippocampus. This is in line with the view that the hippocampus plays a dynamic and time-limited role in arithmetic processing. While the hippocampus seems to be necessary for learning and consolidating new arithmetic facts in memory, it might not be critically involved in retrieving arithmetic facts when these are well consolidated in memory.

Morphometric MRI profiles of multiple system atrophy variants and implications for differential diagnosis

Background

Manual width measurements of the middle cerebellar peduncle on MRI were shown to improve the accuracy of an imaging‐guided diagnosis of multiple system atrophy (MSA). Recently, automated volume segmentation algorithms were able to reliably differentiate patients with Parkinson's disease (PD) and the parkinsonian variant of MSA. The objective of the current study was to integrate probabilistic information of the middle cerebellar peduncle into an existing MRI atlas for automated subcortical segmentation and to evaluate the diagnostic properties of the novel atlas for the differential diagnosis of MSA (parkinsonian and cerebellar variant) versus PD.

Methods

Three Tesla MRI scans of 48 healthy individuals were used to establish an automated whole‐brain segmentation procedure that includes the volumes of the putamen, cerebellar gray and white matter, and the middle cerebellar peduncles. Classification accuracy of segmented volumes were tested in early‐stage MSA patients (18 MSA‐parkinsonism, 13 MSA‐cerebellar) and 19 PD patients using a C4.5 classifier.

Results

Putaminal and infratentorial atrophy were present in 77.8% and 61.1% of MSA‐parkinsonian patients, respectively. Four of 18 MSA‐parkinsonian patients (22.2%) had infratentorial atrophy without evidence of putaminal atrophy. Infratentorial atrophy was present in all MSA‐cerebellar patients, with concomitant putaminal atrophy in 46.2% of these cases. The diagnostic algorithm using putaminal and infratentorial volumetric information correctly classified all PD patients and 96.8% of MSA patients.

Conclusions

The middle cerebellar peduncle was successfully integrated into a subcortical segmentation atlas, and its excellent diagnostic accuracy outperformed existing volumetric MRI processing strategies in differentiating MSA patients with variable atrophy patterns from PD patients. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Impairment of odor discrimination and identification is associated with disability progression and gray matter atrophy of the olfactory system in MS

BACKGROUND

Impairment of odor discrimination (D), identification (I), and threshold (T) are characteristic features of multiple sclerosis (MS).

OBJECTIVE

To identify patterns of gray matter concentration (GMC) associated with different qualities of olfactory function.

METHODS

Olfactory function (T and combined DI score) was measured by Sniffin' Sticks-Test over 2 years longitudinally, and T1-weighted 3-T magnetic resonance imaging (MRI) was performed in 37 MS patients and 18 matched healthy controls (HCs). Statistical parametric mapping (SPM) was applied to objectively identify changes of voxel-wise-GMC throughout the entire brain volume and to correlate image parameters with odor function.

RESULTS

SPM localized significant GMC decreases in the anterior cingulum as well as temporomesial and frontobasal brain areas of the MS group compared with HCs, and revealed significant correlations between lower DI scores and GMC decreases in the olfactory gyrus, anterior cingulum, temporal regions including the parahippocampus, and putamen. Contrarily, no correlations were found between T and GMC. Patients with disability progression had significantly lower mean temporomesial/putamen GMC (0.782 vs 0.804, p = 0.004) compared to patients without Expanded Disability Status Scale (EDSS) progression.

CONCLUSION

Impairment of DI, but not T is associated with GM atrophy in brain regions related to olfactory function. Further studies are warranted to investigate DI scores and temporomesial/putamen GMC as biomarkers for disability progression.

Periodontal Ehlers-Danlos syndrome is associated with leukoencephalopathy

Here, we report brain white matter alterations in individuals clinically and genetically diagnosed with periodontal Ehlers-Danlos syndrome, a rare disease characterized by premature loss of teeth and connective tissue abnormalities. Eight individuals of two families clinically diagnosed with periodontal Ehlers-Danlos syndrome were included in the present study and underwent general physical, dental, and neurological examination. Whole exome sequencing was performed, and all patients included in the study underwent MRI of the brain. Whole exome sequencing revealed heterozygous C1R mutations c.926G>T (p.Cys309Phe, Family A) and c.149_150TC>AT (p.Val50Asp, Family B). All adult individuals (n = 7; age range 31 to 68 years) investigated by MRI had brain white matter abnormalities. The MRI of one investigated child aged 8 years was normal. The MRI pattern was suggestive of an underlying small vessel disease that is progressive with age. As observed in other leukoencephalopathies related to microangiopathies, the extent of the white matter changes was disproportionate to the neurologic features. Medical history revealed recurrent headaches or depression in some cases. Neurological examination was unremarkable in all individuals but one had mild cognitive decline and ataxia and experienced a seizure. The observation that periodontal Ehlers-Danlos syndrome caused by missense mutations in C1R is consistently associated with a leukoencephalopathy opens a new pathogenic link between the classical complement pathway, connective tissue, brain small vessels, and brain white matter abnormalities.