Improved Automatic Segmentation of White Matter Hyperintensities in MRI Based on Multilevel Lesion Features

Brain white matter hyperintensities (WMHs) are linked to increased risk of cerebrovascular and neurodegenerative diseases among the elderly. Consequently, detection and characterization of WMHs are of significant clinical importance. We propose a novel approach for WMH segmentation from multi-contrast MRI where both voxel-based and lesion-based information are used to improve overall performance in both volume-oriented and object-oriented metrics. Our segmentation method (AMOS-2D) consists of four stages following a "generate-and-test" approach: pre-processing, Gaussian white matter (WM) modelling, hierarchical multi-threshold WMH segmentation and object-based WMH filtering using support vector machines. Data from 28 subjects was used in this study covering a wide range of lesion loads. Volumetric T1-weighted images and 2D fluid attenuated inversion recovery (FLAIR) images were used as basis for the WM model and lesion masks defined manually in each subject by experts were used for training and evaluating the proposed method. The method obtained an average agreement (in terms of the Dice similarity coefficient, DSC) with experts equivalent to inter-expert agreement both in terms of WMH number (DSC = 0.637 vs. 0.651) and volume (DSC = 0.743 vs. 0.781). It allowed higher accuracy in detecting WMH compared to alternative methods tested and was further found to be insensitive to WMH lesion burden. Good agreement with expert annotations combined with stable performance largely independent of lesion burden suggests that AMOS-2D will be a valuable tool for fully automated WMH segmentation in patients with cerebrovascular and neurodegenerative pathologies.

Neurobiological correlates of depressive symptoms in people with subjective and mild cognitive impairment

OBJECTIVE

To test the hypothesis that depressive symptoms correlate with Alzheimer's disease (AD) type changes in CSF and structural and functional imaging including hippocampus volume, cortical thickness, white matter lesions, Diffusion tensor imaging (DTI), and fluoro-deoxy-glucose positron emission tomography (FDG-PET) in patient with subjective (SCI) and mild (MCI) cognitive impairment.

METHOD

In 60 patients, depressive symptoms were assessed using the Geriatric Depression Scale. The subjects underwent MRI, 18F-FDG PET imaging, and lumbar CSF extraction.

RESULTS

Subjects with depressive symptoms (n=24) did not have more pathological AD biomarkers than non-depressed. Uncorrected there were trends towards larger hippocampal volumes (P=0.06), less orbital WM damage measured by DTI (P=0.10), and higher orbital glucose metabolism (P=0.02) in the depressed group. The findings were similar when SCI and MCI were analyzed separately. Similarly, in patients with pathological CSF biomarkers (i.e., predementia AD, n=24), we found that correlations between scores on GDS and CSF Aß42 and P-tau indicated less severe AD-specific CSF changes with increasing depression.

CONCLUSION

Depressive symptoms are common in SCI/MCI, but are not associated with pathological imaging or CSF biomarkers of AD. Depression can explain cognitive impairment in SCI/MCI or add to cognitive impairment leading to an earlier clinical investigation in predementia AD.

EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia

BACKGROUND AND OBJECTIVES

The last version of the EFNS dementia guidelines is from 2007. In 2010, the revised guidelines for Alzheimer's disease (AD) were published. The current guidelines involve the revision of the dementia syndromes outside of AD, notably vascular cognitive impairment, frontotemporal lobar degeneration, dementia with Lewy bodies, corticobasal syndrome, progressive supranuclear palsy, Parkinson's disease dementia, Huntington's disease, prion diseases, normal-pressure hydrocephalus, limbic encephalitis and other toxic and metabolic disorders. The aim is to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists and other specialist physicians responsible for the care of patients with dementing disorders. It represents a statement of minimum desirable standards for practice guidance.

METHODS

The task force working group reviewed evidence from original research articles, meta-analyses and systematic reviews, published by June 2011. The evidence was classified (I, II, III, IV) and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided.

RESULTS AND CONCLUSIONS

New recommendations and good practice points are made for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers. All recommendations were revised as compared with the previous EFNS guidelines. The specialist neurologist together with primary care physicians play an important role in the assessment, interpretation and treatment of symptoms, disability and needs of dementia patients.

Reduced cerebrospinal fluid BACE1 activity in multiple sclerosis

Background

Cell and animal experiments have shown that β-site APP-cleaving enzyme 1 (BACE1) may be involved in myelination.

Objective

Here, we assess the association of cerebrospinal fluid (CSF) BACE1 activity with multiple sclerosis (MS).

Methods

BACE1 activity and levels of secreted amyloid precursor protein (APP) and amyloid-β (Aβ) isoforms were analyzed in CSF from 100 patients with MS and 114 neurologically healthy controls. Patients with systemic lupus erythematosus (SLE), 26 with and 41 without cerebral engagement, were also included to enable comparisons with regards to another autoimmune disease. A subset of patients with MS and controls underwent a second lumbar puncture after 10 years.

Results

MS patients had lower CSF BACE1 activity than controls ( P = 0.03) and patients with cerebral SLE ( P < 0.001). Patients with cerebral SLE had higher BACE1 activity than any other group ( P < 0.05 for all comparisons). BACE1 activity correlated with the different amyloid markers in all study groups. BACE1 activity decreased over 10 years in the MS group ( P = 0.039) and correlated weakly with clinical disease severity scores in an inverse manner.

Conclusions

These results suggest an involvement of BACE1 in the MS disease process.

White matter lesion severity is associated with reduced cognitive performances in patients with normal CSF Abeta42 levels

OBJECTIVE

To identify possible associations between white matter lesions (WML) and cognition in patients with memory complaints, stratified in groups with normal and low cerebrospinal fluid (CSF) Abeta42 values.

MATERIAL AND METHODS

215 consecutive patients with subjective memory complaints were retrospectively included. Patients were stratified into two groups with normal (n = 127) or low (n = 88) CSF Abeta42 levels (cut-off is 450 ng/l). Cognitive scores from the Mini-Mental State Examination (MMSE) and the Neurobehavioral Cognitive Status Examination (Cognistat) were used as continuous dependent variables in linear regression. WML load was used as a continuous independent variable and was scored with a visual rating scale. The regression model was corrected for possible confounding factors.

RESULTS

WML were significantly associated with MMSE and all Cognistat subscores except language (repetition and naming) and attention in patients with normal CSF Abeta42 levels. No significant associations were observed in patients with low CSF Abeta42.

CONCLUSIONS

WML were associated with affection of multiple cognitive domains, including delayed recall and executive functions, in patients with normal CSF Abeta42 levels. The lack of such associations for patients with low CSF Abeta42 (i.e. with evidence for amyloid deposition), suggests that amyloid pathology may obscure cognitive effects of WML.

Multimodal imaging in mild cognitive impairment: Metabolism, morphometry and diffusion of the temporal-parietal memory network

This study compared sensitivity of FDG-PET, MR morphometry, and diffusion tensor imaging (DTI) derived fractional anisotropy (FA) measures to diagnosis and memory function in mild cognitive impairment (MCI). Patients (n=44) and normal controls (NC, n=22) underwent FDG-PET and MRI scanning yielding measures of metabolism, morphometry and FA in nine temporal and parietal areas affected by Alzheimer's disease and involved in the episodic memory network. Patients also underwent memory testing (RAVLT). Logistic regression analysis yielded 100% diagnostic accuracy when all methods and ROIs were combined, but none of the variables then served as unique predictors. Within separate ROIs, diagnostic accuracy for the methods combined ranged from 65.6% (parahippocampal gyrus) to 73.4 (inferior parietal cortex). Morphometry predicted diagnostic group for most ROIs. PET and FA did not uniquely predict group, but a trend was seen for the precuneus metabolism. For the MCI group, stepwise regression analyses predicting memory scores were performed with the same methods and ROIs. Hippocampal volume and FA of the retrosplenial WM predicted learning, and hippocampal metabolism and parahippocampal cortical thickness predicted 5 minute recall. No variable predicted 30 minute recall independently of learning. In conclusion, higher diagnostic accuracy was achieved when multiple methods and ROIs were combined, but morphometry showed superior diagnostic sensitivity. Metabolism, morphometry and FA all uniquely explained memory performance, making a multi-modal approach superior. Memory variation in MCI is likely related to conversion risk, and the results indicate potential for improved predictive power by the use of multimodal imaging.

Morphometric changes in the episodic memory network and tau pathologic features correlate with memory performance in patients with mild cognitive impairment

BACKGROUND AND PURPOSE

Mild cognitive impairment (MCI) may affect several cognitive domains, including attention and reasoning, but is often first characterized by memory deficits. The purpose of this study was to ask these 2 questions: 1) Can levels of CSF tau proteins and amyloid beta 42 peptide explain thinning of the cerebral cortex in patients with MCI? 2) How are brain morphometry, CSF biomarkers, and apolipoprotein E (APOE) allelic variation related to episodic memory function in MCI?

MATERIALS AND METHODS

Hippocampal volume and cortical thickness were estimated by MR imaging and compared for patients with MCI (n = 18) and healthy controls (n = 18). In addition, regions of interest (ROIs) were selected in areas where the MCI group had atrophy and which overlapped with the episodic memory network (temporal, entorhinal, inferior parietal, precuneus/posterior cingulate, and frontal). Relationships among morphometry, CSF biomarkers, APOE, and memory were tested. The analyses were repeated with an independent sample of patients with MCI (n = 19).

RESULTS

Patients with MCI and pathologic CSF values had hippocampal atrophy. However, both patients with pathologic and patients with nonpathologic CSF had a thinner cortex outside the hippocampal area. CSF pathology was related to hippocampal volume, whereas relationships with cortical thickness were found mainly in one of the samples. Morphometry correlated robustly with memory performance across MCI samples, whereas less stable results were found for tau protein.

CONCLUSION

The differences in hippocampal volume between the MCI and the healthy control groups were only found in patients with pathologic CSF biomarkers, whereas differences in cortical thickness were also found for patients without such pathologic features. Morphometry in areas in the episodic memory network was robustly correlated with memory performance. It is speculated that atrophy in these areas may be associated with the memory problems seen in MCI.

Diaschisis after thalamic stroke: a comparison of metabolic and structural changes in a patient with amnesic syndrome

INTRODUCTION

We present a patient with a left anteromedial thalamic lesion with an amnesic syndrome. The patient underwent neuropsychological testing, cerebrospinal fluid (CSF) analyses, magnetic resonance imaging (MRI) [T2, flair, and diffusion tensor imaging (DTI)] and [18F]-2-fluoro-deoxy-d-glucose positron emission tomography (FDG-PET) to assess indirect effects of thalamic lesions on cortical function.

CASE REPORT

A 67-year-old right-handed woman was admitted to a university-based memory unit because of memory and concentration problems. Neuropsychological testing revealed dysfunction of episodic memory, semantic memory and working memory. General intellectual function and attention capacity were preserved. MRI revealed an anteromedial thalamic lesion in the left hemisphere. FDG-PET showed decreased uptake in the frontal, parietal and temporal lobes of the left hemisphere. Regions of interest (ROI) in white matter were selected and left and right hemispheres were compared. Fractional anisotropy (FA) in ROI representing thalamo-cortical connections were decreased in the left hemisphere when compared with the right.

CONCLUSION

The results show the importance of a network that include the anterior and dorsomedian nuclei, which influence the activity in areas of the cortex responsible for memory processes. The imaging findings suggest that areas of cortical diaschisis after thalamic infarction correspond to areas affected by thalamo-cortical fibre loss as measured with FA.

Associations between white matter lesions, cerebrovascular risk factors, and low CSF Abeta42

OBJECTIVE

To analyze a putative relationship between white matter lesions (WMLs), risk factors for WMLs, and Alzheimer disease (AD) as measured with the surrogate marker CSF Abeta42.

METHODS

The authors analyzed effects of acquired risk factors for cerebrovascular disease and WMLs on AD as measured with an intermediate marker, CSF Abeta42. A total of 127 consecutive patients with subjective memory impairment (mean age 66 years; 57 women) investigated at a university-based memory clinic had brain MRI scans. WMLs were rated on a 12-point scale with a semiquantitative procedure. They used path analysis with established and possible risk factors for WMLs and for reduced CSF Abeta42 (age, hypertension, hyperhomocysteinemia, hypercholesterolemia, APOE-epsilon4) as variables.

RESULTS

The WML score was 1.5 points higher (p < 0.05) in hypertensive than in nonhypertensive patients and 1.9 points higher (p < 0.05) in patients with hyperhomocysteinemia than in those with normal homocysteine levels. Hypercholesterolemia increased the probability of low CSF Abeta42 levels by 0.2 (p < 0.05). For each point increase in WML score, the probability of low CSF Abeta42 levels increased by 0.03 (p < 0.05). APOE-epsilon4 was associated with reduced CSF Abeta42 (p < 0.01).

CONCLUSION

Both hypercholesterolemia and white matter lesions may contribute to low CSF Abeta42 by independent mechanisms.

Organic brain disease in psychogeriatric patients: impact of symptoms and screening methods on the diagnostic process

Psychogeriatric patients are mentally affected by a heterogeneous group of diseases, traditionally classified as functional or organic brain disorders (OBDs). Here, we evaluate screening procedures with respect to revelation of underlying OBD. Fifty consecutive patients admitted to a psychogeriatric unit dedicated to late-onset psychiatric disease were included. Diagnosis at admission, symptoms, and time of onset of disease were determined blindly by an independent, experienced psychiatrist on the basis of referral documents and the interview written at admission. Subsequently, consensus established a clinical diagnosis (after psychiatric and neurologic evaluations) and a final diagnosis after the screening procedures (Cognistat and MMS-tests, electroencephalograms, computed tomography, and SPECT). Conventional criteria (ICD-10, ICPC) were used for diagnostic classification. Only 10 of the 50 patients were diagnosed with OBD at admission and an additional 7 patients following full clinical evaluations. At final diagnosis, 34 (of 46) patients were diagnosed with significant OBD. The Cognistat test had the largest diagnostic impact, with sensitivity/specificity values of 81%/60% for OBD.

Denervation enhances spontaneous inflammatory myopathy in SJL mice

We studied the effect of denervation on the spontaneous inflammatory myopathy that occurs in SJL mice. Cryosections from innervated and denervated calf muscles were assessed for severity of inflammation, relative proportions of mononuclear cell subsets, and major histocompatibility complex (MHC) class I expression. A significant increase in mononuclear cell infiltrates occurred in the denervated muscle. Denervation also changed the composition of mononuclear cell infiltrates towards a higher percentage of CD8(+) T cells (19% versus 11%). MHC class I expression was enhanced in denervated muscle compared with innervated muscle. Our findings indicate that inflammation in muscle may be enhanced by denervation.

[The amyloid and tau hypothesis in degenerative dementia]

Alzheimer's disease is the major cause of dementia. The neuropathological basis for the diagnosis is the presence of senile plaques and neurofibrillary degeneration in brain tissue. Senile plaques consist of a central core of fibrillar amyloid beta-protein and some other proteins, surrounded by swollen neurites. Three genes causing early-onset autosomal dominant Alzheimer have so far been described. Recently, polymorphisms in three other genes have been shown to influence the risk for late-onset Alzheimer's disease. All these genes seem to influence the metabolization of the beta-protein or the precursor for this protein. These findings support the "amyloid hypothesis" which states that toxic effects of beta-protein cause Alzheimer's disease. Frontotemporal dementias are the second most common types of degenerative dementias, and may account for more than 10% of the dementias. A substantial number of these cases are probably caused by a mutation in the gene for tau protein on chromosome 17.

Human leukocyte antigen class I in polymyositis: leukocyte infiltrates, regeneration, and impulse block

In polymyositis (PM), T-cell mediated myocytotoxicity is directed against strongly human leukocyte antigen class I positive (HLA-I+) muscle fibers. Fiber regeneration probably is partly responsible for this HLA-I up-regulation. We have evaluated regeneration, denervation/impulse blockade, and focal leukocyte infiltrates as possible HLA-I inducing factors in PM. Distinctive patterns of HLA-I, nerve cell adhesion molecule (NCAM), and vimentin expression accompany denervation and regeneration. Regenerating fibers also have centralized nuclei. Using semiquantitative methods, we examined strongly HLA-I+ fibers in PM muscle biopsies for these markers. Sarcoplasmic HLA-I levels were related to the presence of leukocyte infiltrates and invasion of fibers. Strongly HLA-I+ fibers were frequently invaded, and regeneration-associated changes were usually observed at sites of fiber damage. Sarcoplasmic HLA-I levels were stable along intact fibers, also adjacent to leukocyte infiltrates. A majority of the strongly HLA-I+ fibers were nonregenerating (NCAM+ only). Though other mechanisms cannot be excluded, this suggests that impulse blockade or denervation may contribute to extra HLA-I up-regulation in these fibers.

Development of homogeneous fast and slow motor units in the neonatal mouse soleus muscle

We studied the fiber type composition and contractile properties of mouse soleus motor units at 2 days, 5 days and 2 weeks of age. We used Lucifer Yellow injection to mark muscle fibers belonging to the same motor unit in the two youngest age groups, and the traditional method of glycogen depletion in the oldest. The age groups were chosen because 2 days is at the end of muscle fiber production; 5 days is at the start of synapse elimination in the muscle and 2 weeks is at the end. Muscle fibers were classified as fast (F) or slow (S) on the basis of their myosin heavy chain (MHC) content, as determined by different monoclonal antibodies. Motor units are already dominated by either F- or S-fibers at 2 days, suggesting an early preferential innervation of the two types of fibers. A substantial part of the remaining refinement of the innervation takes place during the next 3 days, while the total number of terminals in the muscle remains constant. This is most easily explained by an exchange of aberrant for correct synapses during this period. A smaller part of the refinement of the innervation occurs during the subsequent period of synapse elimination.

Development of homogeneous fast and slow motor units in the neonatal mouse soleus muscle

We studied the fiber type composition and contractile properties of mouse soleus motor units at 2 days, 5 days and 2 weeks of age. We used Lucifer Yellow injection to mark muscle fibers belonging to the same motor unit in the two youngest age groups, and the traditional method of glycogen depletion in the oldest. The age groups were chosen because 2 days is at the end of muscle fiber production; 5 days is at the start of synapse elimination in the muscle and 2 weeks is at the end. Muscle fibers were classified as fast (F) or slow (S) on the basis of their myosin heavy chain (MHC) content, as determined by different monoclonal antibodies. Motor units are already dominated by either F- or S-fibers at 2 days, suggesting an early preferential innervation of the two types of fibers. A substantial part of the remaining refinement of the innervation takes place during the next 3 days, while the total number of terminals in the muscle remains constant. This is most easily explained by an exchange of aberrant for correct synapses during this period. A smaller part of the refinement of the innervation occurs during the subsequent period of synapse elimination.

The perinatal reorganization of the innervation of skeletal muscle in mammals

(1) The perinatal reorganization of muscle innervation is executed in a setting established by the earlier embryonic developmental processes. Prominent among these is the generation of a stereotyped set of skeletal muscles, each innervated in an orderly fashion from an appropriate pool of spinal motoneurons. The muscles contain functionally specialized types of fibers which differentiate in patterns characteristic for each muscle even without innervation. (2) Cholinergic motoneurons are required for functional innervation of skeletal muscles. In addition the muscle fibers must be in a receptive state. Denervation or paralysis recreates the receptive state. Chemically the receptive state is not well defined. It is associated with an immature distribution of AChRs and NCAM. (3) Nmjs are located in an orderly fashion on muscle fibers. Their normal distribution can be disrupted by paralysis during development. When junctions are first formed the nerve terminal induces local aggregation, stabilization and mature ionophore kinetics of the AChRs, as well as appearance of junctional specific AChE. Some of the effects require muscle activity. Terminal-derived substances like agrin and CGRP may normally contribute to these processes, as may other not yet identified agents. (4) Numerically, motoneuronal pools are regulated according to the available target. At the same time, the generation of secondary myotubes requires innervation by active motoneurons, and may also be quantitatively regulated by the number of innervating motoneurons. The generation of the primary generation of myotubes is independent of innervation. (5) Soon after the muscle fiber is first innervated additional terminals from other axons form junctions at the same site. The extent of polyneuronal innervation differs between muscles and between fiber types in the same muscle. Following a delay of several days after birth the individual terminals increase their contact area by arborization. The postsynaptic differentiation with redistribution of AChR, AChE and formation of subsynaptic folds is initiated. The complete maturation of the endplate requires several weeks. (6) Around birth or a few days later processes which eliminate redundant terminals are initiated. The rate of elimination appears to be aimed at nearly synchronous completion of the process in muscles with related functions. (7) There are two types of processes involved in the elimination of supernumerary terminals. The one gives rise to a competitive interaction between terminals innervating the same muscle fiber. The second is related to the reduction in the number of terminals which a motoneuron can maintain in the muscle. The two normally act in concert to determine the mature pattern of innervation of a muscle.(ABSTRACT TRUNCATED AT 400 WORDS)

Postnatal loss of synaptic terminals in the normal mouse soleus muscle

Using conventional physiological techniques for measuring unitary contractions and end-plate potentials (epps), the number, size and segmental properties of motor units (MUs) in the soleus muscle of the mouse during postnatal development have been examined. The number of MUs remains constant after birth, and there is no evidence of segmental preferences in the innervation pattern, before, during or after the postnatal elimination of redundant terminals. In neonates, MU size estimates based on twitch contractions are 30% smaller than tetanic estimates. Intracellular recording of epps shows that this is caused by facilitation of epps on repetitive stimulation. The frequency of occurrence of epps in the muscle from a few, isolated motor axons shows that the average motoneuron contacts 36% of the fibres in the muscle neonatally. A substantial fraction of the contacts is subthreshold for twitch activation of their fibre. The MU size remains constant up to day 5. During the next 10 days, the MU size is reduced to the mature value of 5% of the fibres in the muscle. It is concluded that the neonatal loss of synaptic terminals in this muscle takes place without concomitant loss of entire motor neurons, and that it is independent of possible segmental preferences in the innervation of the muscle.

Postnatal loss of synaptic terminals in the partially denervated mouse soleus muscle

The present work aims to distinguish between processes that lead to neonatal synapse elimination. We have partially denervated the mouse soleus muscle just after birth by cutting one (L5) of the two (L4 and L5) spinal nerves which supply its innervation. After 4-6 weeks' survival times, we determined the number of remaining motor units (MUs) and the number of innervated fibres in the muscle by conventional physiological and histological techniques. There was no significant overlap between the remaining MUs. Their average size was reduced from about 230 muscle fibres at birth to about 80 after 4-6 weeks, compared to only 30 in normal animals of the same age. We conclude that two processes are required to explain synapse elimination in the muscle: a non-competitive process, inherent to the immature motor neurons and leading to a substantial reduction in their field of innervation; a competitive process between axon terminals innervating the same muscle fibre.